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OF  CALIFORNIA 

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BUILDING  A 
PROFITABLE  PRACTICE 


BEING  A  TEXT-BOOK  ON 
MEDICAL    ECONOMICS 


BY 

THOMAS  F.  REILLY,  M.S.,  M.D. 

PROFESSOR  OF  APPLIED   THERAPEUTICS,  MEDICAL  DEPARTMENT  FORDHAM 
UNIVERSITY,  NEW   YORK   CITY 


PHILADELPHIA  6r'  LONDON 

J.   B.   LIPPINCOTT  COMPANY 

^1^ 


COPTRIOHT,   1912 
BT  J.  B.  LiPPINCOTT  COMPANT 


Printed  by  J.  B.  lAppineetl  Companv 
The  Wathington  Square  Frees,  Philadelphia,  U.  S.  A. 


Biomedical 
Libraiy 

w 

Ijia  Preface 

At  the  commencemeiit  of  a  medical  career,  many 
great  problems  face  the  beginner.  It  is  for  many 
men  the  most  momentous  time  in  their  career. 
Errors  made  then  are  frequently  never  righted, 
habits  acquired  are  seldom  changed,  and  the  whole 
building  of  a  medical  education  may  collapse  and  the 
graduate  enter  another  line  of  work  and  activity. 
Sometimes  the  most  insignilScant  causes  bring  about 
these  results. 

As  the  time  draws  near  for  the  reception  of  your 
diploma,  each  one  begins  to  think  of  the  future.  You 
have  been  drilled  in  the  science  and  art  of  medicine, 
and  it  shall  be  the  aim  of  this  discourse  to  correlate 
what  has  gone  before  with  the  usage  of  the  profes- 
sion, and  to  teach  the  business  principles  underlying 
the  successful  practice  of  medicine. 

^lany  men  well  skilled  in  the  science  of  medicine 
are  lamentable  failures  when  it  comes  to  actual  prac- 
tice ;  not  so  much  from  their  failure  to  understand, 
to  diagnose,  and  to  treat  disease  as  to  make  a  liveli- 
hood, and  to  know  how  to  get  along  with  their  pa- 
tients and  other  doctors.  It  may  be  well  for  such 
to  pause  and  to  ask  the  reason  therefor,  and  how  can 
this  be  better  done  than  by  a  retrospective  view  of 
one*s  life  from, the  date  of  graduating? 

Thomas  F.  Reilly. 

August  15,  1912. 


6';'6790 


Introduction 

The  contents  of  this  volume  are  the  results 
largely  of  notes  made  in  the  first  few  years  of  prac- 
tice. They  represent  the  problems  that  presented 
themselves  to  the  author  in  the  early  days  of  prac- 
tice and  often  seemed  more  troublesome  than  diffi- 
cult medical  cases.  It  is  not  intended  as  a  vade 
mecum  for  the  older  practitioner.  As  far  as  the 
author  is  aware  there  is  no  work  on  medical  eco- 
nomics that  bridges  the  chasm  between  the  medical 
school  and  actual  practice.  The  science  of  medi- 
cine is  taught,  but  there  is  no  text-book  that  teaches 
the  student  the  modus  operandi  of  getting  patients 
to  offer  themselves  for  the  exercise  of  this  skill 
which  he  has  tried  so  hard  to  acquire. 

The  substance  of  this  work  was  originally  em- 
bodied in  a  series  of  lectures  delivered  for  the  past 
five  years  to  the  graduating  class  of  Fordham 
University. 

The  author  has  received  much  help  and  many 
suggestions  from  various  books  and  authors,  not- 
ably from  the  book  on  **  The  Physician  Himself." 
Due  credit  is  given  at  the  end  of  each  chapter  to 
the  more  important  sources  of  information.  It  is 
interesting  to  note  that  as  early  as  the  twelfth  cen- 
tury lectures  on  this  subject  were  given  by  Archi- 
mattheas,  at  Salerno.  The  instruction  for  the  imme- 
diate coming  of  the  physician  to  his  patient  runs 

V 


vi  INTRODUCTION 

as  follows :  *  *  When  the  doctor  enters  the  dwelling 
of  his  patient,  he  should  not  appear  haughty,  nor 
covetous,  but  should  greet  with  kindly,  modest 
demeanor  those  who  are  present,  and  then  seating 
himself  near  the  sick  man  accept  the  drink  which  is 
offered  him  {sic)  and  praise  in  a  few  words  the 
beauty  of  the  neighborhood,  the  situation  of  the 
house,  and  the  well-known  generosity  of  the  fam- 
ily,— if  it  should  seem  to  him  suitable  to  do  so.  The 
patient  should  be  put  at  his  ease  before  the  exami- 
nation begins  and  the  pulse  should  be  felt  deliber- 
ately and  carefully.  The  fingers  should  be  kept  on 
the  pulse  at  least  until  the  hundredth  beat  in  order 
to  judge  its  kind  and  character;  the  friends  stand- 
ing round  will  be  all  the  more  impressed  because 
of  the  delay,  and  the  physician's  words  will  be  re- 
ceived with  just  that  much  more  attention."  "  On 
the  way  to  see  the  sick  person  he  (the  physician) 
should  question  the  messenger  who  has  summoned 
him  upon  the  circumstances  and  the  conditions  of 
the  illness  of  the  patient;  then,  if  not  able  to  make 
any  positive  diagnosis  after  examining  the  pulse 
and  the  urine,  he  will  at  least  excite  the  patient  *s 
astonishment  by  his  accurate  knowledge  of  the 
symptoms  of  the  disease  and  thus  win  his  confi- 
dence.** He  says,  **  When  the  doctor  quits  the  pa- 
tient he  should  promise  him  that  he  will  get  quite 
well  again,  but  he  should  inform  his  friends  that 
he  is  very  ill ;  in  this  way,  if  a  cure  is  effected,  the 
fame  of  the  doctor  will  be  so  much  the  greater,  but 
if  the  patient  dies  people  will  say  that  the  doctor 


INTRODUCTION  vii 

had  foreseen  the  fatal  issue."    (See  Walsh  in  **  Old 
Time  Makers  of  Medicine.") 

In  most  schools  the  instruction  has  consisted  in 
the  giving  of  one  such  lecture  each  year.  Under 
the  system  of  preceptors,  this  was  probably  suffi- 
cient because  the  student  imbibed  enough  practical 
knowledge  from  his  preceptor  to  fit  him  for  the 
struggle  for  existence.  It  is  the  hope  of  the  author 
that  his  work  may  serve  to  keep  at  least  a  few  from 
falling  into  the  thousand  pitfalls  that  threaten  the 
beginner.  If  it  shaU  save  at  least  one  such,  then  the 
work  has  not  been  done  in  vain. 


Contents 

CHAPTER  I. 

PAOB 

The  Economics  of  Medicine 1 

Hospital  Appointments  and  Interneship 1 

CHAPTER  II. 

Pobt-Graduate  Study 8 

United  States 8 

Europe 8 

Germany 11 

Vienna 12 

London 14 

Scotland 15 

Paris 16 

CHAPTER  III. 

The  Hospital  and  Dispensary  Service 19 

Hospital  Positions 19 

Dispensary 20 

CHAPTER  IV. 

State  Board  Examinations  and  Licenses 23 

Interstate  Reciprocity 23 

Privilege  of  Attending  Cases  in  other  States 24 

CHAPTER  V. 

Location 26 

CHAPTER  VI. 

The  Office 33 

Instruments 37 

Medicines 42 

Books 42 

Reception  Room 43 

Cards  and  Letter  Heads 45 

Office  Hours 45 

As  to  Two  Offices 47 

The  Doctor's  House 47 


X  CONTENTS 

CHAPTER  VII.  PAQB 

EZTBA-PRACnCE  SOUBCES  OP  INCOME 49 

Anny 60 

Navy 61 

Public  Health  and  Marine  Hospital  Service 61 

Insane  Hospital  Service 54 

Merchant  Marine 57 

Insurance  Examiners 60 

Health  Department 62 

Medical  Journalism 64 

Lodge  Practice 64 

Pathological  Examinations 66 

CHAPTER  VIII. 

The  Start  in  Practice 68 

Buying  a  Practice 68 

Partnerships 69 

Seeing  Doctors  in  the  Neighborhood 70 

CHAPTER  IX. 

Medical  Societies 71 

Advantages 71 

Medical  Papers 73 

Presentation  of  Patients 76 

Membership  in  American  Medical  Association 83 

CHAPTER  X. 

The  Ofpice  Call 85 

History-taking 85 

Examination  of  the  Patient 87 

CHAPTER  XI. 

First  Visit. 94 

When  to  Repeat  Calls 100 

Discharging  a  Patient 103 

Management  of  Incurables 104 

Management  of  Dying  Patient 104 

When  a  Patient  is  Already  Dead 106 

Sending  Patients  to  Hospitals 106 

CHAPTER  XII. 
Nurses 109 


CONTENTS  ri 

CHAPTER  XIII.  PAGE 

Medical  Finance Ill 

Fees 112 

For  Night  Call 113 

For  Office 114 

For  Obstetric  Cases 116 

Collection  of  Midwifery  Fees 117 

For  Operative  Cases 119 

Fee  Table 119 

Orthopedic 126 

Pathological 127 

For  Rendering  Assistance  to  Other  Doctors 127 

For  Treatment  of  Other  Doctors 129 

For  Treatment  of  Dentists  and  Clergy 131 

For  Accident  Cases 133 

Curbstone  Prescriptions,  Free  Advice,  Etc 135 

Charging  Rich  and  Poor 136 

CHAPTER  XIV. 

Collections 138 

Send  Bills  Regularly 141 

Forms  of  Collecting  Letters 146 

Disputed  Claims 151 

Collection  Agents 152 

Responsibility  for  Bills  and  Legal  Collection  of  Same 154 

CHAPTER  XV. 
Bookkeeping 160 

CHAPTER  XVI. 

The  Law  and  the  Doctor 163 

Malpractice 163 

Revocation  of  License 168 

Autopsies 169 

Stopping  Visits 170 

Medical  Defence 170 

CHAPTER  XVII. 

Professional  Ethics 172 

Criticism  of  Other  Physicians 172 

Dismissal  from  Case 175 

What  Cases  You  May  Take  in  Your  Office 175 

Ethics  of  Insurance  Examiners 182 

The  Substitute 183 


xii  CONTENTS 

CHAPTER  XVIII.  PACT 

Advertising,  Etc 185 

Boaating  about  Cases 188 

CHAPTER  XIX. 

Commissions 189 

Patents  and  JVoprietaries 192 

CHAPTER  XX. 

Consultation  and  Consultant 193 

The  Consultation 196 

The  Consultants 202 

CHAPTER  XXI. 

Certificates 205 

Health 206 

Birth 205 

Death 206 

Insurance 207 

Reporting  Contagious  Diseases 208 

CHAPTER  XXII. 

I*ROGNOSIS 210 

Prognosis  of  Death 213 

CHAPTER  XXIII. 

Diagnosis 215 

CHAPTER  XXIV. 

Errors  in  Practice 218 

CHAPTER  XXV. 

Dispensing 220 

CHAPTER  XXVI. 

Religious  Rites,  Etc 223 

CHAPTER  XXVII. 

Obstetric  Cases  and  Emergencies 227 

Eclampsia 234 

Hysteria 236 


CONTENTS  xiii 

CHAPTER  XXVIII.  PACT 

Abortion 236 

CHAPTER  XXIX. 
The  Doctor  as  a  Specialist 243 

CHAPTER  XXX. 
Automobile  vs.  Horse  and  Carriage 246 

CHAPTER  XXXI. 

On  Drugs  and  the  Pharmacist 249 

Changing  Medicines,  Etc 255 

Apparatus,  Etc 256 

The  Detail  Man  and  the  Proprietaries 256 

CHAPTER  XXXII. 

Building  up  an  Office  Practice 259 

Stomach  Cases 260 

Neurasthenia 261 

CHAPTER  XXXIII. 

Aids  in  Practice 263 

The  Treatment  of  Children 263 

Habits 263 

Diet  Slips 264 

Interest  in  the  Ordinary  Case 265 

Sexual  Discussion 267 

Accident  Adjusters 267 

CHAPTER  XXXIV. 
On  Making  Friends 268 

CHAPTER  XXXV. 
Personal  Manners 271 

CHAPTER  XXXVI. 
Personal  Appearance 274 

CHAPTER  XXXVII. 
Mabriage 278 


xhr  CONTENTS 

CHAPTER  XXXVIII.  page 

Don'ts  in  Practicb 280 

Investments 280 

Health  and  Accident  Instirance 280 

Religioua  Beliefs 281 

Preaching  Morals 283 

CHAPTER  XXXIX. 

Answers  to  Patients 284 

Vacation,  Etc 287 

CHAPTER  XL. 
Yotm  Life  Wobk. 288 


ILLUSTRATIONS. 

PAGE 

Interne's  Quarters  in  a  Large  Hospital 4 

Surgical  and  Nerve  Clinics  op  the  Royal  Charit6,  Berlin    12 
Compact  and  Convenient  Arrangement  op  Desk,  Card  Index, 

AND  Lights 36 

United  States  Army  Medical  Tent,  with  Full  Equipment 50 

New  Hall  College  op  Physicians,  Philadelphia 72 

Examining  a  Patient  Under  Sheet 88 

Instrument  Case  Showing  Sliding  Glass-covered  Shelves.  .  118 

Orthopedic  Gymnasium 126 

Handy  Arrangement  of  Desk,  Reference  Books,  and  Type- 
writer    142 

Bucket  Method  of  Opening  and  Cleansing  Intestines,  Espe- 
cially Useful  in  Private  Autopsies 168 

Ideal  Examining-room  of  a  Consultant  Gynecologist 202 

Quick  Reference  Working  Library 210 

Arrangement  of  Bed,  Table,  and  Chair  for  Normal  Labor  232 
Corner  of  an  Office  Equipped  to  Specialize  on  the  Eye  . .  244 

Types  of  Prescription  Writing 250 

Playthings,   an   Aid   in  the   Office  in  Examining   Young 

Children 276 


BUILDING  A 
PROFITABLE  PRACTICE 


CHAPTER  I. 

The  Economics  of  Medicine. 

hospital,  appointments  and  interneship. 

We  will  suppose  that  you  have  succeeded  in  get- 
ting your  diploma.  What  are  you  going  to  do  ?  My 
personal  advice  for  those  who  can  possibly  do  so, 
is  to  seek  hospital  interneship.  It  may  seem  a  long 
time  to  devote  one  or  two  years,  after  the  law  allows 
you  to  make  money,  in  the  pursuit  of  knowledge 
without  any  financial  return,  but  this  experience  is 
equivalent  to  the  experience  of  ten  years  in  actual 
practice;  more  than  that,  it  teaches  you  the  limita- 
tions of  your  confreres,  and  in  addition  broadens 
your  charity  to  all  men. 

In  active  practice  you  will  probably  never  see 
the  same  limits  of  practice,  the  poor  and  the  rich, 
the  good  and  the  bad,  grouped  together  under  simi- 
lar environments,  and  you  will  nowhere  see  human 
nature  so  completely  unadorned.  The  advice  of  a 
friend  who  lacked  the  hospital  experience,  when 
asked  the  question  if  he  should  take  an  interneship 
by  a  recent  graduate,  still  rings  in  my  ear,  "If  you 

1 


S        BUILDING  A  PROFITABLE  PRACTICE 

can't  afford  it,  borrow  the  money,  if  you  cannot 
borrow  it,  steal  it,"  and  shows  in  a  way  the  value 
of  such  an  education. 

These  hospital  appointments  are  usually  to  be 
had  as  the  result  of  competitive  examination.  The 
attending  physicians  realize  that  this  is  often  a 
mistake,  as  in  many  instances  the  readiest  man  at 
an  examination  fails  signally  as  a  house  oflBcer  or 
mayhap  is  so  disagreeable  personally  that  every 
one  is  glad  when  his  term  of  service  is  over.  As  it 
seldom  or  never  happens  that  an  interne  is  dis- 
missed without  some  grave  reason,  this  is  all  the 
more  onerous  on  those  who  must  come  in  contact 
with  him. 

For  this  reason  it  is  advisable  to  present  your- 
self to  as  many  as  possible  of  the  members  of  the 
examining  board  of  the  institution  as  well  as  the 
secretary  of  the  board  where  you  will  seek  position, 
with  the  greatest  possible  number  of  letters  of  rec- 
ommendation as  to  your  ability,  character,  etc.,  but 
above  all,  as  to  your  mixibility  if  I  may  use  the 
term. 

Take  all  the  hospital  examinations  that  you  can, 
as  you  will  learn  more  catch  questions  and  practical 
points  in  a  half  dozen  such  examinations  than  in  a 
month  of  medical  education.  Don't  despise  the 
small  hospitals  located  in  the  suburbs.  In  many 
instances  they  offer  better  opportunities  for  gen- 
eral practice  than  the  large  metropolitan  institu- 
tions. Many  hospitals  have  a  medical  and  surgical 
service.    If  possible  do  not  take  an  exclusively  sur- 


THE  ECONOMICS  OF  MEDICINE  3 

gical  service.  You  will  get  very  little  surgery  in 
the  first  few  years  of  your  practice. 

A  general  medical  service  is  the  most  useful  for 
the  recent  graduate.  Hospitals  devoted  to  special- 
ties, as  obstetrics,  eye,  children,  etc.,  usually  demand 
as  a  requisite  that  the  applicant  has  had  a  previous 
general  hospital  service.  The  experience  that  you 
will  need  mostly  in  your  early  days  is  psediatric,  and 
this  service  is  usually  difficult  to  get. 

If  you  do  take  a  hospital  appointment,  try 
to  make  the  close  personal  acquaintance  of  one  of 
the  members  of  the  visiting  staff,  as  it  will  be  many 
a  dollar  in  your  pocket. 

He  will  probably  be  flattered  by  your  attentions 
and  will  do  all  in  his  power  to  advance  his  protege 
after  you  leave  the  institution. 

THE   INTERNE. 

While  in  the  hospital  do  not  forget  for  one  mo- 
ment that  you  are  always  a  pupil  and  a  servant; 
even  though  some  little  authority  is  given  to  you. 

The  notoriously  swelled  head  that  most  hospital 
physicians  acquire  while  internes  is  responsible  for 
the  sneering  smiles  of  the  near-by  practising  phy- 
sicians. This  applies  with  greater  truth  to  the  am- 
bulance surgeon  than  to  any  other.  Even  the  laity 
are  constantly  laughing  at  the  pompous  arrogance 
of  the  ambulance  surgeon. 

His  ambitious  statements  to  the  reporters  of  the 
press  are  daily  excitants  of  laughter  and  ridicule. 
His  wonderful  diagnoses  face  us  on  every  page.    I 


4        BUILDING  A  PROFITABLE  PRACTICE 

pray  you  avoid  these  marvellous  exploitations  of 
your  genius.  Some  hospitals  have,  in  addition  to 
the  regular  staff  of  internes,  one  or  more  men  who 
live  outside  and  yet  do  much  routine  hospital  work 
— they  are  termed  externes.  Failing  to  get  an  in- 
temeship,  an  extemeship  is  not  to  be  despised. 
If  you  fail  to  get  a  place,  you  can  often  secure  one 
by  advertising  in  the  medical  press.  You  will  find 
many  opportunities  to  substitute  for  a  month  or  so 
in  most  hospitals  while  the  residents  are  on  vaca- 
tions. It  is  also  well  to  do  this  during  your  senior 
and  junior  vacation.  The  story  is  told  of  the  man 
having  one  of  the  largest  general  practices  in  New 
York  who,  failing  to  get  a  place  on  the  staff  at 
Bellevue,  went  in  as  a  trained  nurse  for  a  year  or 
two  to  get  the  experience.  His  after-success  justi- 
fied his  humility. 

While  in  the  hospital  be  courteous  to  the  physi- 
cians living  in  the  neighborhood  and  to  all  of  those 
sending  cases  to  the  institution.  Nothing  gives  a 
hospital  such  a  bad  reputation  as  a  succession  of 
assertive  internes  who  ridicule  and  sneer  at  the 
diagnoses  and  treatment  accorded  patients  prior  to 
their  entry  into  the  hospital.  The  interne  gener- 
ally takes  the  patient's  word  at  full  value  and 
thinks  that  the  attending  physician  must  be  an  old 
fogy  because  he  calls  an  enteritis  a  bloody  dysen- 
tery, etc.,  or  a  lobar  pneumonia  an  inflammation  of 
the  lungs.  As  a  consequence  of  such  remarks  the 
practising  physician  is  apt  to  criticise  the  hospital 
at  every  opportunity.  Furthermore,  when  you  go  out 


THE  ECONOMICS  OF  MEDICINE  6 

into  active  practice  the  fact  that  you  told  patients 
that  they  would  have  died  if  they  had  not  come  to 
the  hospital  when  they  did  will  make  the  old  physi- 
cian watch  you  carefully.  It  is  wiser  to  praise  the 
physicians  who  have  previously  attended  all  of  the 
cases  on  your  service,  as  it  does  the  hospital  no  harm 
and  helps  yourself  and  everyone  else. 

Cultivate  the  friendship  of  the  patient  while  an 
interne,  and  also  the  friendship  of  the  friends  of 
the  patient,  as  by  just  that  many  more  people  you 
will  be  known  after  you  get  out  in  practice.  While 
I  do  not  advise  you  to  do  it,  the  graduates  of  a 
certain  large  hospital  in  this  city  get  the  names  and 
addresses  of  all  the  patients  that  they  treated  dur- 
ing their  hospital  service,  and  send  cards  to  them, 
announcing  their  start  in  practice.  This  is  not 
ethical.  If  people  have  become  acquainted  with  you 
and  really  like  you,  they  will  look  you  up  when  they 
wish  your  services ;  at  any  rate,  they  will  know  who 
you  are  when  your  name  is  mentioned. 

Treat  all  the  nurses  uniformly,  and  you  will  not 
be  the  object  of  jealous  remarks.  Be  pleasant  to 
them  at  all  times.  Nurses  may  often  be  the  means 
of  sending  patients  to  you  in  your  early  practice. 
Unfortunately,  friendliness  between  nurse  and  doc- 
tor, because  of  the  fact  that  matters  of  a  sexual  na- 
ture are  supposed  by  the  laity  to  be  an  open  book 
to  them,  is  often  misinterpreted.  Be  scrupulous  in 
this  matter.  As  a  house  officer,  don't  elevate  the 
head  nurse  over  the  junior  physicians,  as  is  the  cus- 
tom in  some  institutions.    Keep  the  nurses  in  their 


6        BUILDING  A  PROFITABLE  PRACTICE 

place  and  do  not  joke  with  them.  For  the  most  part 
they  idealize  you  and  think  that  you  are  infinitely 
greater  than  you  really  are.  Levity  brings  you 
down  from  this  pedestal.  Furthermore,  it  is  gen- 
erally misinterpreted,  both  by  the  nurse  and  the 
patients.  Your  jokes  are  taken  very  seriously  by 
your  hospital  patients,  and  the  nurse  will  presume 
to  skip  her  duties  if  she  thinks  you  are  very 
friendly.  In  many  hospitals  the  attentions  of  the 
house  staff  to  the  nurses  are  a  cause  for  dismissal 
of  the  nurse.  This  is  especially  so,  if  it  be  known 
that  they  have  gone  to  a  theatre,  etc.,  together.  This 
works  a  hardship  on  the  girl,  although  you  will  sel- 
dom be  punished  for  it.  Many  women  go  into  the 
nursing  profession  with  the  avowed  object  of  mar- 
rying a  doctor,  particularly  an  interne;  such  girls 
even  come  from  the  very  best  families.  The  uni- 
form and  the  surroimdings  of  a  hospital,  which 
often  serve  to  bring  out  all  of  the  best  and  most 
womanly  traits  in  a  woman,  often  make  a  deep  im- 
pression on  a  young  man  at  the  most  impression- 
able age.  In  some  cases  at  least  the  other  side 
of  the  temperament  is  not  in  evidence;  so  do  not 
be  in  too  great  a  hurry  to  try  to  make  a  living  for 
some  one  else  before  you  know  whether  you  can 
swim  yourself. 

While  it  is  undoubtedly  true  that,  for  purposes 
of  discipline,  there  should  not  be  too  much  freedom 
between  members  of  a  hospital  staff,  still  in  most 
hospitals  the  studied  reserve  of  the  house  physician 
toward  the  senior,  and  he  in  turn  toward  the  junior, 


THE  ECONOMICS  OF  MEDICINE  7 

is  generally  carried  too  far.  Because  you  are  six 
months  older  in  medicine  than  your  confrere,  does 
not  confer  on  you  the  title  and  knowledge  of  the 
gods.  A  hearty  cooperation  secures  better  service, 
both  for  the  staff  and  for  the  institution.  Don't  lord 
it  over  the  man  who  comes  from  a  smaller  college 
than  yourself.  He  has  studied  the  same  text-books 
as  yourself,  and  doubtless  knows  as  much,  if  not 
more,  than  you  do.  In  after-life,  on  the  other  hand, 
because  you  are  a  graduate  of  some  prominent  hos- 
pital, don't  put  on  that  '^  holier  than  thou  "  expres- 
sion which  so  often  characterizes  the  former  in- 
ternes of  some  metropolitan  colleges  and  hospitals. 
Holding  a  retractor  for  a  top-notch  surgeon  does 
not  mean  that  his  genius  has  been  conveyed  to  you 
by  any  particular  form  of  animal  magnetism. 

Before  leaving  the  hospital,  ask  the  opinion  of 
all  of  the  attending  physicians  and  surgeons  as  to  a 
suitable  place  for  beginning  practice.  They  are  in 
a  position  to  know  of  any  good  berths  that  may  be 
open. 


CHAPTER  II. 

Post-Graduate  Study. 

in  the  united  states. 

Afteb  you  have  finished  your  hospital  course  and 
if  you  do  not  feel  like  beginning  practice,  a  year  or 
two  spent  in  post-graduate  study  in  America  or 
Europe  is  of  great  advantage.  There  are  post- 
graduate schools  in  Chicago,  Philadelphia  and  New 
York.  The  best  known  schools  are  the  New  York 
Post-Graduate,  the  New  York  Polyclinic,  the  Phila- 
delphia Polyclinic,  and  the  Chicago  Post-Graduate. 
The  New  York  schools  are  the  largest  and  best  or- 
ganized, although  very  good  instruction  may  be  had 
elsewhere.  In  many  lines  of  work  the  post-gradu- 
ate schools  in  this  country  are  equal,  if  not  supe- 
rior, to  those  conducted  on  the  continent.  They 
are,  however,  better  fitted  for  the  one  who  has  been 
in  general  practice  some  time  than  for  the  beginner, 
whereas  the  European  schools  are  organized  to  fit 
both  classes.  In  these  American  schools  there  are 
courses  in  almost  every  branch  of  medicine  and  sur- 
gery. The  cost  varies,  but  averages  $25  for  a  six 
weeks*  course.  Inasmuch  as  several  courses  are 
taken  at  the  same  time,  a  period  of  six  weeks  will 
cost  about  $125. 

IN    EUROPE. 

The  call  of  Europe  will  always  be  answered  by 
some  of  you,  and  for  that  reason  a  brief  outline  of 

8 


POST-GRADUATE  STUDY  9 

foreign  post-graduate  instruction,  as  far  as  it  ap- 
plies to  Americans,  will  be  presented.  Not  a  few 
go  to  Europe  for  the  prestige,  but  that  seldom  counts 
very  much,  unless  one  has  been  well  established  for 
some  years  in  some  locality  before  going  abroad. 
Anyone  contemplating  such  a  trip  should  commence 
his  preparations  at  least  four  months  in  advance. 
Letters  of  introduction  to  foreign  professors,  unless 
they  come  from  very  close  friends  of  the  professor 
or  from  the  very  leaders  in  the  profession,  are  prac- 
tically useless.  A  hundred  dollars  is  worth  more 
than  a  bushelful  of  letters.  If  you  intend  to  go 
to  France  or  Germany  or  Austria,  a  working  knowl- 
edge of  the  language  is  necessary.  It  is  true  that 
there  are  courses  in  English  in  Vienna  and  a  few 
in  Berlin,  but  they  are  not  of  much  value.  German 
is  the  language  of  Vienna.  A  course  of  15  or  20 
recitations  with  a  competent  teacher  of  languages 
here  will  make  a  good  preparation.  In  Berlin  and 
Vienna  you  will  find  many  who  will  complete  your 
education  in  the  language  at  moderate  prices.  It 
is  customary  to  board  at  residences  where  only 
German  is  spoken,  and  this  increases  your  vocabu- 
lary. Any  of  the  medical  centres  of  England, 
Germany,  France  or  Austria  will  afford  plenty  of 
instruction.  Germany  and  Austria  are  now  the 
chosen  places  for  the  medical  man,  much  as  Paris 
was  a  century  ago.  Time  spent  under  these  Teutonic 
influences  is  valuable,  not  only  because  of  the 
amount  of  knowledge  gained,  but  more  so  because 
of  the  ever-present  examples  of  enthusiasm  in  the 
cause  of  medicine  as  a  science.    Nowhere  are  there 


10      BUILDING  A  PROFITABLE  PRACTICE 

so  many  young  men  willing  to  work  in  laboratories 
and  clinics  for  years  and  years,  with  only  the  slight- 
est hope  of  promotion.  Everything  in  life  is  sub- 
ordinated to  the  attainment  of  the  title  of  Professor. 
The  result  of  this  idealization  is  shown  by  the  fact 
that  more  than  half  of  the  masters  of  medicine 
today  are  of  Teutonic  origin.  As  a  consequence, 
in  Germany  a  doctor  is  *'  somebody,"  and  your 
visiting  card  with  the  title  of  M.D.  thereon  is  pro- 
ductive of  as  much  respect  as  the  badge  of  the  Legion 
of  Honor  would  secure  elsewhere.  There  is  scarcely 
a  field  of  research  existent  but  that  you  will  find  a 
leader  in  the  subject  in  some  of  the  large  cities  of 
Germany. 

You  should  next  secure  a  passport  by  writing  to 
the  Department  of  State,  Washington,  D,  C,  for 
the  necessary  credentials.  This  you  may  register 
with  the  consul  when  you  arrive.  You  must  find 
out  in  a  general  way  when  the  courses  that  you 
wish  to  enter  begin,  and  whether  there  are  vacan- 
cies. If  you  intend  to  go  to  Berlin,  the  Year  Book 
of  the  Anglo-American  Medical  Association  con- 
tains all  of  the  necessary  information.  This  you 
should  write  for,  enclosing  stamps,  address,  Anglo- 
American  Medical  Association,  Friedrich-Strasse 
105  B,  Berlin.  Courses  not  contained  in  this 
book  you  will  find  in  the  **  Verzeichnis  der  Vorle- 
sungen  "  (List  of  University  Courses),  25  cents  in 
foreign  stamps;  also  "  Freie  Kurse  fiir  praktische 
Aerzte"  (Free  Courses  for  Practising  Physicians). 
These  may  be  obtained  at  the  above  address. 


POST-GRADUATE  STUDY  11 

GEBMANY. 

The  twentieth  of  the  month  is  the  best  time  to  ar- 
rive in  Berlin,  as  this  allows  you  time  to  get  set- 
tled and  to  make  course  arrangements.  The  courses 
start  on  the  first  of  the  month.  In  Berlin,  medical 
courses  are  divided  into  (1)  the  regular  university 
courses,  which  are  given  to  undergraduate  students ; 
(2)  vacation  courses,  given  by  the  university  instruc- 
tors during  March  and  October;  (3)  monthly  courses 
by  private  instructors,  which  are  given  all  the  year. 
These  latter  correspond  to  our  post-graduate  school 
work,  with  the  exception  that  they  are  usually  not 
given  under  one  roof  as  is  the  case  here.  Attendance 
at  the  regular  university  courses  is  not  apt  to  be  in- 
teresting to  you,  but  it  is  generally  free.  The  vaca- 
tion courses  in  October  and  March  are  bargain- 
counter  courses  and  last  for  one  month.  A  position 
as  voluntary  assistant  to  a  professor  is  often  allow- 
able in  out-patient  departments  and  even  in  the  hos- 
pitals. Your  compatriots  will  generally  try  to  place 
you,  if  you  are  agreeable.  On  arriving  in  Berlin, 
it  is  a  good  plan  to  go  at  once  to  the  Cafe  '  *  Kaiser- 
krone,"  corner  of  Friedrich-  and  Karl-Strasse,  and 
there,  between  11  a.m.  and  3  p.m.,  you  will  meet  some 
of  your  compatriots,  who  will  give  you  all  of  the 
necessary  information  as  to  cost  of  rooms,  etc. 

In  many  of  the  smaller  cities  in  Germany  much 
good  study  may  be  done.  In  some  ways  these 
smaller  places  are  better  than  the  large  centres,  be- 
cause there  are  not  so  many  students,  but  unless 


12      BUILDING  A  PROFITABLE  PRACTICE 

you  are  quite  familiar  with  the  German  language, 
it  is  wiser  to  go  to  the  capitals.  Among  the  smaller 
cities,  Munich  offers  splendid  opportunities  in 
psycliiatry  and  diseases  of  the  eye,  because  of 
Kraepelin  and  Eversbusch.  The  usual  fee  here  is 
$15  per  course.  In  Leipsic,  there  are  no  organized 
courses  for  foreigners,  but  one  can  do  good  work  in 
the  clinics. 

Heidelberg  is  an  attractive  place,  and  by  reason 
of  the  presence  of  Erb  Krehl  and  Czerny,  is  gen- 
erally visited  by  Americans.  At  Frankfort,  Ehr- 
lich's  laboratory  is  the  Mecca  that  attracts  those  of 
a  biochemical  turn  of  mind.  At  Strassbourg,  some 
of  the  best  research  work  in  the  world  has  been 
done,  and  the  genius  of  Schmiedeberg,  Naunyn  and 
Krehl  still  makes  this  a  Mecca  for  clinician  and 
laboratory  worker.  It  is  a  quiet  place,  with  every 
opportunity  for  study.  At  Hamburg,  Lehnhartz  is 
a  commanding  figure ;  at  Breslau,  Neisser  and  Min- 
kowski ;  at  Jena,  Stitzing  and  Riedel ;  at  Wiirzburg, 
Leube;  at  Cologne,  there  is  good  post-graduate 
instruction  that  is  well  organized,  \vith  Bardenheur 
and  Tillmans.  The  Academy  of  Practical  Medicine 
at  Diisseldorf  offers  courses  in  most  of  the  major 
specialties  at  a  nominal  fee  of  $1.25. 

VIENNA. 

If  Vienna  be  the  goal,  write  to  the  American 
Medical  Association  of  Vienna,  Cafe  Klinik,  corner 
Spital-  und  Lazarethgasse.    This  association  issues 


GIimi«es  of  Medical  Europe  (Thompson). 

Surgical  Clinic. 


Glimpses  of  Medical  hurope  (Thompson 


Nerve  Clinic. 
Royal  Charite,  Berlin. 


POST-GRADUATE  STUDY  13 

a  book  of  courses  with  full  explanations;  it  costs 
20  cents  and  postage.  A  complete  list  of  lectures 
and  courses,  given  during  the  winter  and  summer 
and  vacation,  is  contained  in  the  official  catalogues, 
(1)  *'  Verzeichnis  der  offentlichen  Vorlesungen  an 
der  Wiener  Universitat  im  Winter  und  Sommer  " 
and  also  (2)  '*  Verzeichnis  der  Ferialkurse. "  These 
may  be  had  by  enclosing  10  cents  for  each  book  in 
foreign  postage,  to  Rob.  Coen,  IX,  Alserstrasse  6, 
Vienna,  Austria.  A  hand-book  in  German,  English 
and  French  of  the  post-graduate  medical  work  is 
also  published  by  Urban  &  Schwarzenberg,  I.  Maxi- 
millianstrasse  4,  Vienna,  sent  free ;  enclose  stamps. 

The  cost  of  living  averages  from  $10  to  $12  per 
week.  There  are  splendid  opportunities  for  dis- 
sections in  Institute  of  Anatomy,  and  for  pathology 
in  the  Pathological  Institute.  Those  courses  cost 
$10  to  $15  for  eight  weeks.  The  following  schedule 
represents  the  typical  cost  of  courses:  Diagnosis, 
$10;  hematology,  $25,  6  weeks;  surgery  of  ear,  $20, 
8  weeks;  rhinology,  $20-$40,  including  usually  one 
major  operation  on  the  patient  to  be  performed  by 
the  student.  A  special  class  for  any  branch  or  spe- 
cialty can  generally  be  had  if  the  lecturer  is  guar- 
anteed a  minimum  fee,  varying  from  $100  to  $150 
for  the  entire  class.  To  anyone  wishing  to  do  the 
work  of  an  interne,  the  position  of  Hospitant  in  the 
wards  is  generally  obtainable.  They  have  the  same 
rights  as  the  house  physician,  but  no  duties. 

On  arriving  in  Vienna,  go  to  the  Cafe  Klinik, 
corner  Spital-  and  Lazarethgasse,  opposite  the  en- 


14      BUILDING  A  PROFITABLE  PRACTICE 

trance  of  the  Public  Hospital,  known  as  the  "  All- 
gemeine  Krankenhaus. "  Here  you  will  meet  your 
countrymen,  who  will  be  only  too  glad  to  give  you 
all  the  necessary  information  as  to  board,  etc.  The 
good  fellowship  that  characterizes  the  English- 
speaking  student  at  Vienna  is  one  of  the  most  strik- 
ing things  abroad.  The  headquarters  of  the  Ameri- 
can Medical  Association  of  Vienna  is  at  present  at 
the  Cafe;  the  association  numbers,  at  times,  a  hun- 
dred and  fifty  men. 

LONDON. 

In  London  there  is  now  a  grand  opportunity  to 
study.  The  post-graduate  work  is  in  charge  of  the 
associated  schools  of  medicine  of  London  for  post- 
graduate teaching.  The  course  consists  in  admis- 
sion to  the  ward  and  out-patient  departments  of 
fifteen  of  the  largest  hospitals  in  London.  Lectures 
are  given,  post-mortems  performed,  and  a  vast 
amount  of  clinical  material  is  utilized.  Such  a 
course  is  of  greater  benefit  to  the  young  practitioner 
than  special  courses,  unless  he  has  determined  to 
specialize  early  in  his  career.  The  cost  of  such  a 
course  is  $50  for  three  months,  and  $75  for  six 
months.  The  advantages  are  that  a  knowledge  of 
English  is  all  that  is  required.  One  must  have  cre- 
dentials that  you  are  a  graduate  in  medicine.  Appli- 
cation should  be  made  to  the  oflSce  of  the  Post- 
Graduate  Association,  20  Hanover  Square,  London, 
W.    There  is  another  large  post-graduate  school. 


POST-GRADUATE  STUDY  15 

known  as  the  Medical  Graduate's  College  and  Poly- 
clinic, 22  Chemies  St.,  London,  W.  C.  This  insti- 
tution offers  all  sorts  of  instruction  in  medicine, 
surgery  and  the  more  important  specialties,  for  $5 
per  year.  The  North  East  London  Post-Graduate 
College  has  a  course  in  surgery  for  $26,  special 
courses  for  $5 ;   address  Prince  of  Wales  Hospital. 

The  West-London  Post-Graduate  College  also 
furnishes  post-graduate  instruction. 

The  Liverpool  School  for  Study  of  Tropical 
Medicine  also  takes  post-graduate  students. 

In  Dublin,  the  Rotunda  Hospital  is  the  Mecca 
for  those  interested  in  obstetrics.  Probably  no  other 
teaching  institution  in  English-speaking  countries 
compares  with  it  in  this  line  of  work. 

SCOTLAND. 

In  Scotland,  the  post-graduate  courses  are  well 
organized,  both  in  Edinburgh  and  Glasgow.  The 
work  in  Edinburgh  is  controlled  by  the  Royal  Uni- 
versity, and  a  letter  addressed  to  the  university  will 
secure  all  the  needed  information.  One  of  the  best 
courses  extends  from  the  first  Monday  in  August  to 
the  end  of  September ;  the  cost  is  about  $10  a  week. 
In  Glasgow,  the  control  is  vested  in  the  Glasgow 
Royal  Infirmary.  In  Edinburgh,  the  courses  are 
given  each  year  in  August  and  September,  some- 
times extending  into  October.  The  courses  in 
Glasgow  run  about  the  same  way  as  those  in  Edin- 
burgh.   Honan  very  aptly  suggests  that  for  the 


16      BUILDING  A  PROFITABLE  PRACTICE 

American  arriving  in  Europe  for  study  in  the  sum- 
mer, a  good  plan  would  be  to  spend  August  and 
September  in  Scotland  and  England,  going  to  Ber- 
lin late  in  October,  when  the  German  professors  have 
returned  from  their  vacations,  and  when  active  work 
begins. 

PARIS. 

In  Paris,  there  is  no  well-organized  post-grad- 
uate instruction,  but  if  one  knows  what  he  wants, 
he  can  generally  find  excellent  teaching  in  any  par- 
ticular branch  of  practice.  A  card  of  admission  to 
all  of  the  hospitals  of  Paris  may  be  obtained  from 
Administration  G«nerale  de  Assistance  Publique, 
Avenue  Victoria  3.  However,  usually  one  is  well 
received  at  any  of  the  hospitals  at  9  o'clock  in  the 
morning,  by  simply  presenting  your  visiting  card  to 
the  doorman,  with  a  request  that  it  be  sent  in  to  the 
professor  whose  work  you  wish  to  witness. 

The  courses  organized  during  the  year  are  posted 
in  the  building  of  the  Faeulte  de  Medecine.  The 
Presse  Medicale  often  contains  announcements  of 
such  courses.  The  fees  vary  from  $10  to  $20. 
Courses  are  organized  twice  a  year  at  No,  18,  Rue 
de  Luxembourg,  in  May  and  in  November.  The 
course  at  the  Pasteur  Institute  is  from  three  to  four 
months  long,  and  is  given  twice  a  year.  Inquiry 
should  be  made  to  Dr.  Roux  as  to  vacancies,  etc.  A 
general  bureau  of  information  on  all  of  these  mat- 
ters, with  attendants  speaking  English,  can  be  foimd 
at  Bureau  de  Reseignement  Scientifique  at  the  Sor- 


POST-GRADUATE  STUDY  17 

borne.  Board  in  the  Latin  quarter  costs  from  $30 
to  $40  per  month. 

Information  in  regard  to  post-graduate  medical 
courses  in  all  countries  is  to  be  had  from  the  Medical 
Information  Bureau,  Kaiserin  Friedrich  Haus,  Ber- 
lin (postage). 

Any  one  of  the  places  mentioned  above  offers 
good  enough  facilities  for  the  young  practitioner.  In 
general,  one  is  more  benefited  by  post-graduate 
work  done  after  five  or  six  years  of  general  practice. 
At  that  time  one  begins  to  have  leanings  toward 
certain  lines  of  work  wherein  he  feels  that  he  could 
do  better  work.  He  is  then  in  a  position  to  discard 
the  branches  of  lesser  importance,  and  if  you  go  to 
Europe  after  some  years  of  general  practice,  the 
hygienic  benefit  will  be  greater. 

REFERENCE  BOOKS. 

Thompson:     Glimpses  of  Medical  Europe,  J.  B.  Lippineott  Co. 

Honan's  Handbook  to  Medical  Europe,  P.  Blakiston  &  Co. 

Hall,  I.  N. :  Post-Graduate  Work  in  Vienna,  J.  A.  M.  A.,  Dec.  7, 
1907. 

Osier,  Wm.:  Vienna  and  Paris,  J.  A.  M.  A.,  May  9,  1908;  Feb. 
27,  1909;  March  6,  1909. 

Davis,  A.  S. :  Vienna,  Journal  Ophthal.  and  Otology,  April, 
1909. 

Mannheimer:  Post-Graduate  Study  in  Europe,  Medical  Record, 
May  8,  1909. 

Deney:    Psychiatry  in  Munich,  J.  A.  M.  A.,  Jan.  1,  1910. 

Kast :  International  Conference  on  Medical  Education,  The  Poat- 
Graduate,  June,  1910. 

Slocum:  The  American  Medical  Student  in  Vienna,  Phys.  & 
Surgeon,  July,  1910. 

An  English  Handbook  to  the  Paris  Medical  School,  P.  Blakiston. 

t 


18      BUILDING  A  PROFITABLE  PRACTICE 

GERMAN-ENGLISH  BOOKS. 

GSerman-English  Medical  Dialogue  (Lewin),  published  by  Dr. 
Werner   Klinkhardt,    Leipsic. 

Medical  Vade  Mecum  in  English  and  German,  B.  Lewis.  P. 
Blaki8ix>n,  $5. 

This  is  the  best  work  of  its  kind,  and  while  the  cost  is  a 
little  more,  it  is  worth  it. 

Self-taught  French,  Spanish,  German,  Italian.  By  Dick  & 
Fitzgerald,  18  Ann  St.,  N.  Y.     Very  cheap. 

Deutch:  Medical  Grerman — a  very  good  book,  J.  H.  Vail  & 
Co.,  N.  Y. 

The  Journal  of  the  American  Medical  Association  supplied 
the  above  index  of  articles. 

The  Continental  Anglo-American  Medical  Society 
consists  of  a  majority  of  the  English-speaking  phy- 
sicians practising  medicine  in  Continental  Europe, 
and  it  may  be  of  value  to  have  a  list  of  such  names, 
either  because  of  sickness  or  social  reasons.  Dr. 
Chas.  J.  James,  St.  Boulevard  Malesherbes,  Paris, 
will  furnish  the  list  on  application  (postage).  It  is 
also  contained  in  the  1912  Edition,  Medical  Directory 
of  the  American  Medical  Association. 


CHAPTER  III. 

The  Hospital  and  Dispensary  Service, 
hospital  positions. 

Hospital  positions,  i.e.,  appointments  on  the  vis- 
iting staff,  will  not  come  to  you  for  years ;  ten  years 
is  all  too  early  for  such  appointments.  These  posi- 
tions require  much  judgment  and  responsibility,  and 
you  will  be  sharply  watched,  and  your  mistakes  will 
be  all  too  evident. 

However,  there  is  not  much  likelihood  of  your 
getting  such  a  place.  In  most  cases  they  are  ob- 
tained through  favoritism  and  usually  come  only 
after  years  of  service  in  the  dispensary.  Besides 
this  they  require  a  great  deal  of  time  which  means 
loss  of  money  within  the  first  decade.  An  assistant- 
ship  is  the  most  that  you  can  reasonably  hope  for ; 
take  it  by  all  means  if  you  can  get  it. 

If  you  do  not  have  the  opportunity  to  take  a  hos- 
pital position  as  an  interne,  the  next  best  thing  to 
do  is  to  get  some  practical  experience  in  a  dis- 
pensary. Whether  you  have  had  a  hospital  in- 
terneship  or  not  dispensary  experience  is  of  the 
greatest  service  as  it  is  more  like  the  ordinary  run 
of  office  practice  than  the  hospital  service.  If  pos- 
sible get  into  a  dispensary  near  your  home.  One 
connected  with  a  hospital  is  better  than  otherwise. 

19 


20      BUILDING  A  PROFITABLE  PRACTICE 

DISPENSARY. 

In  a  large  city  almost  any  one  in  charge  of  the 
dispensary  will  gladly  receive  you,  and  if  you  will 
content  yourself  for  a  few  months  with  doing  the 
clerical  work,  such  as  taking  the  names  and  ad- 
dresses of  patients,  histories,  etc.,  and  are  disposed 
to  be  humble,  you  will  find  a  place. 

It  is  far  better  to  go  in  as  an  assistant  to  some 
older  man  than  to  have  sole  charge  of  a  clinic  your- 
self. Also  it  is  a  good  plan  if  you  can  possibly  ar- 
range it,  to  get  into  a  different  class  or  specialty 
every  three  or  four  months.  In  this  way  you  will 
become  posted  on  all  of  the  common  diseases  of  the 
specialties.  However,  don't  spend  more  than  three 
hours  a  week  in  dispensaries.  Be  prompt  at  your 
dispensary  and  treat  all  of  these  cases  with  as  much 
consideration  as  though  they  were  paying  you. 

It  is  not  permissible  to  get  any  outside  practice 
from  dispensaries  as  a  rule,  and  it  seldom  pays.  Be 
scrupulous  in  this  regard,  as  it  will  always  come  to 
the  ears  of  the  patient's  former  medical  adviser  and 
he  will  resent  it.  You  will  seldom  get  much  finan- 
cial return  for  such  services.  Some  dispensaries 
make  it  a  rule  not  to  allow  the  attending  physician 
to  give  his  address  to  patients.  Others  are  not  so 
particular. 

Don't  go  into  the  dispensary  with  the  hope  of 
becoming  chief  of  clinic  in  a  few  months  or  years. 
That  would  be  a  calamity  to  yourself.  You  must 
have  the  older  men  show  you  the  thousand  and  one 


HOSPITAL  AND  DISPENSARY  SERVICE     21 

things  that  are  not  put  down  in  the  text-books.  Good 
hard  work  always  counts,  but  do  not  expect  to  get 
at  30  years  of  age  what  you  should  have  at  40,  nor 
at  40  what  you  should  have  at  50.  One  finds  any 
amount  of  men  who  have  the  desire  and  ambition  to 
become  professors,  but  the  great  majority  want  the 
position  handed  out  to  them  at  once.  Long,  hard 
years  of  preparation  is  the  only  way  that  anyone  can 
maintain  such  a  position  as  visiting  physician  or 
that  of  a  professor.  It  is  only  recently  that  a  young 
man  with  more  riches  and  ambition  than  others  was 
asked  to  resign  from  his  position  as  attending 
physician  to  a  large  hospital,  because  he  was  not 
better,  or  in  some  cases  as  well  posted  on  medical 
matters,  as  the  internes.  The  humiliation  of  such 
a  case  should  be  a  warning  to  all  that  such 
positions  should  not  be  accepted  until  one  is 
well  grounded  in  experience.  Now  the  practice 
of  medicine  seems  like  an  open  book  to  you — 
everything  clear,  clean-cut,  but  10  or  15  years 
from  now  you  will  not  think  that  you  know 
quite  so  much  about  diseases.  This  is  no  place  to 
discuss  the  ethics  of  treating  rich  and  poor  at  the 
dispensary.  Yet  I  feel  that  you  should  not  treat 
anyone  who  is  able  to  pay  an  outside  physician.  It 
is  a  hardship  on  the  dispensary  physician  to  be 
compelled  to  question  patients'  ability  to  pay.  Yet 
there  are  so  many  people  who  take  advantage  of 
the  free  and  easy  supply  of  medical  charity  that 
something  ought  to  be  done.  These  people  will 
sometimes  tell  you  that  they  believe  that  they  will 


82      BUILDING  A  PROFITABLE  PRACTICE 

get  better  treatment  at  the  dispensarj'^  than  else- 
where. In  such  a  case,  let  them  consult  the  dispen- 
sary physicians  at  their  homes,  and  a  complete  list 
of  the  dispensary  officers  may  be  given  to  such  a 
one.  If  this  is  impossible,  don't  give  such  a  one 
any  more  consideration  than  the  poor  and  lonely 
one  who  comes  dressed  in  threadbare  clothing. 

You  go  to  the  dispensary  principally  to  get  ex- 
perience, and  financial  consideration  should  not 
sway  you;  but  good,  steady  work  in  a  dispensary 
will  give  you  a  reputation  among  a  clientele  that 
will  often  mean  a  fair  fee  from  some  of  their  friends 
who  will  hear  of  you. 

Take  an  interest  in  the  dispensary  patient  and 
treat  him  as  carefully  as  though  you  were  being  paid 
for  it.  It  will  command  his  respect  and  you  will 
profit  by  the  experience.  There  is  a  strong  ten- 
dency in  dispensaries  to  be  **  short  "  with  patients, 
to  treat  them  according  to  a  routine  and  to  give 
them  no  consideration  when  they  ask  any  questions 
as  to  diagnosis  and  prognosis.  This  is  not  fair  nor 
just.  It  is  partly  due  to  the  esprit  de  corps  of  the 
dispensary  and  partly  to  the  ignorant,  disagreeable 
class  of  patients  that  frequent  such  clinics.  Be  kind 
to  all  and  avoid  this  dispensary  manner,  which  is  so 
common  and  so  easily  acquired,  or  you  will  surely 
unconsciously  carry  it  into  your  private  work,  much 
to  the  disgust  of  your  patients. 


CHAPTER  IV. 

State  Boaed  Examinations  and  Licenses. 

As  a  general  rule  the  student  who  has  taken  a 
four-year  course  in  an  academy  or  high  school  of 
the  first  class  with  a  four-year  course  in  a  medical 
college  is  eligible  for  any  State  board  examination. 
Passing  examinations  is  a  kind  of  mental  gymnastic 
exercise  that  belongs  to  youth  and  youth  only.  You 
probably  have  now  more  of  the  knowledge  that  de- 
lights examiners  than  you  will  ever  have  again.  So 
pass  your  State  board  examination  as  soon  as  pos- 
sible. It  is  customary  to  review  the  work  in  the  form 
of  quiz  compend,  for  a  week  or  two  beforehand. 
In  many  States  a  book  is  published  by  the  Regents 
giving  the  questions  at  all  State  board  examinations 
in  that  State  for  the  past  five  years.  In  default  of 
this  "Goepp  on  State  Board  Medical  Examination'* 
or  Medical  Record  State  Board  Examinations,  will 
be  found  quite  satisfactory.  This  covers  the  ques- 
tions and  answers  in  all  of  the  States. 

interstate  reciprocity. 

There  is  a  small  pamphlet  covering  all  of  the 
questions  of  interstate  reciprocity;  what  require- 
ments are  necessary  in  each  State,  and  under  what 
conditions  licenses  of  other  States  are  accepted. 
This  pamphlet  is  published  by  the  American  Medi- 

2S 


24       BUILDING  A  PROFITABLE  PRACTICE 

cal  Association,  under  the  title  of  '*  Laws  Regulat- 
ing the  Practice  of  Medicine  in  the  United  States 
and  Elsewhere,"  and  can  be  had  for  a  trifle  at  535 
Dearborn  Street,  Chicago,  111. 

PErVTLEGE  OF  ATTENDING  CASES  IN  OTHER  STATES. 

NoN-EESiDENT  physiciaus  and  surgeons  are  ac- 
corded the  privilege  of  attending  patients  within 
their  jurisdiction,  by  the  following  States:  Cali- 
fornia, Connecticut,  District  of  Columbia,  Indiana, 
Kentucky,  Maine,  Maryland,  Massachusetts,  Miss- 
issippi, New  Hampshire,  New  Jersey,  New  York, 
North  Carolina,  Ohio,  Oklahoma,  Pennsylvania,  Ver- 
mont and  Wyoming,  but  they  are  not  allowed  to 
have  an  office  in  the  State,  unless  licensed.  New 
Jersey  permits  a  physician  of  another  State  to  take 
temporary  charge  of  a  practice  of  a  physician,  if  a 
notice  be  filed  with  the  State  Board.  You  must  reg- 
ister your  certificate  or  license  with  some  desig- 
nated county  officer  in  the  county  in  which  you 
reside  and  where  you  will  practise.  Whether  you  can 
practise  in  another  county  in  the  same  State  with- 
out registering  your  license  is  an  open  question. 
You  can  always  attend  cases  outside  of  the  county, 
but  it  is  not  always  lawful  to  open  an  office  in 
another  county,  unless  you  file  a  copy  of  your  li- 
cense in  that  county.  The  rule  holds  good  that 
States,  granting  the  reciprocity  mentioned  above, 
allow  consultants  from  other  States  to  see  cases 
with  resident  physicians.    Practically,  there  is  very 


STATE  BOARD  EXAMINATIONS  25 

little  trouble  in. this  matter;  it  is  only  in  the  case 
of  physicians,  living  on  the  border  of  the  State,  that 
there  is  likely  to  be  any  friction.  In  such  cases,  the 
courts  usually  are  very  liberal  in  their  interpreta- 
tion of  the  law. 


CHAPTER  V. 
Location. 

Most  men  will  be  anxious  to  get  to  work  as  soon 
as  possible  and  the  great  question  is  where  to  locate. 
If  one  could  afford  a  trip  across  the  continent  at  the 
entrance  of  practice,  I  am  confident  that  many  would 
locate  in  the  Western  fields  of  promise.  The  pro- 
fession is  more  respected  and  better  compensated 
there  than  in  the  East,  and  I  would  strongly  advise 
a  transcontinental  trip  if  one  could  afford  it  before 
settling  down. 

This  is  out  of  the  question  for  most  of  you,  so 
which  shall  it  be,  the  large  city  or  the  small  town, 
generally  called  the  country! 

From  the  time  of  Horace,  pa^es  have  been  writ- 
ten on  the  pleasures  of  both.  It  is  certainly  easier 
to  get  a  living  practice  in  the  country  place  earlier 
than  in  the  large  city.  The  eventual  possibilities  are 
not  so  great  and  there  is  always  the  complaint  of 
"what  might  have  been"  in  the  ambitious  mind. 
The  work  is  considerably  harder,  more  pleasant, 
less  confining,  more  honored,  and  less  exacting  from 
a  technical  standpoint. 

If  ambition  to  more  than  make  a  living  and  enjoy 
the  comforts  of  life  has  fired  your  soul;  if  you 
wish  to  climb  the  heights  of  science  to  secure  the 
plaudits  of  your  fellows,  then  the  largest  field  for 
your  activity  should  be  your  goal.    The  place  with 

26 


LOCATION  27 

the  most  opportunities  for  study,  advancement  and 
eventual  financial  gain,  is,  of  course,  the  large  city, 
the  city  of  a  million  or  more.  There  is  always  one 
consolation  in  such  a  location,  that  you  will  never 
have  to  feel,  after  years  of  hard  labor  and  study 
with  only  moderate  success,  that  you  have  missed 
anything.  Simply  you  did  not  have  the  ability. 
''What  might  have  been"  is  the  saddest  epitaph 
of  any  life.  On  the  other  hand,  financial  success 
comes  much  more  slowly  and  is  not  so  permanent. 
By  this,  I  mean  that  patients  change  much 
more  quickly  in  large  cities  than  in  the  smaller 
places.  When  one  has  a  family  in  the  small  town, 
in  a  large  proportion  of  cases  he  has  the  whole 
family  for  life.  This  is  not  so  in  the  large  city.  One 
often  finds  two  or  three  doctors  attending  in  the 
same  family,  and  there  is  a  growing  tendency  to  re- 
gard all  doctors  like  dentists  as  very  much  alike. 
Again,  the  city  physician  does  not  have  the  long 
night  calls  that  his  country  brother  must  occasion- 
ally make.  He  has  his  opportunities  for  medical 
education  in  the  medical  societies,  libraries,  etc.,  and 
intercourse  with  his  intellectual  equals,  together  with 
his  laboratories,  aid  him  in  diagnosis.  The  city 
hospitals,  too,  take  care  of  troublesome  cases,  give 
counsel  in  difficult  cases,  and  administer  to  the  pa- 
tient 's  comfort.  One  must  not  think  for  one  moment 
that  he  does  not  pay  a  heavy  tax  for  all  of  those 
advantages.  It  is  incumbent  on  yourselves  to  choose 
whichever  of  these  two  pictures  appeals  to  you.  One 
will  succeed  in  one  condition,  where  he  might  fail 


28      BUILDING  A  PROFITABLE  PRACTICE 

in  the  other,  although  I  believe  that  the  one  who 
makes  a  prominent  success  in  one  field  would  at 
least  have  done  passing  well  in  the  other. 

The  polished  and  affable,  the  scientifically  in- 
clined would  shine  to  advantage  in  the  city ;  but  what 
use  is  there  in  pointing  out  such  things,  as  every- 
one thinks  he  possesses  these  and  similar  virtues! 
Voila! 

If  your  ambition  in  life  is  to  amass  a  comfortable 
competence  for  your  old  age,  to  raise  a  family  and 
to  be  respected  by  the  community ;  if  you  are  fond  of 
the  country,  its  greenness  and  its  trees;  if  your 
health  demands  it,  then,  by  all  means,  hie  yourself 
to  the  small  town;  no  one  goes  to  practise  in  the 
country  itself.  There  are  few  towns  that  do  not 
boast  of  more  than  one  doctor.  The  automobile  and 
telephone  have  made  the  farmer  your  next-door 
neighbor.  If  you  have  the  choice,  of  course  you  will 
settle  in  a  prosperous  country.  Don't  locate  in  a 
neighborhood  where  the  fees  average  as  low  as  50 
or  75  cents  a  house  visit.  It  is  practically  impossi- 
ble for  you  ever  to  make  a  living  in  such  a  commu- 
nity. Don't  go  into  a  decaying  community,  or  one 
where  there  are  no  industries,  nor  good  farms.  The 
fact  that  there  is  another  physician  in  town  does  not 
lessen  your  chances.  There  is  no  man,  no  matter 
how  good  and  clever  he  may  be,  but  has  enemies  or 
dissatisfied  clients;  these  people  may  be  entirely 
honest  in  their  likes  and  dislikes  and  will  be  only  too 
anxious  to  employ  and  boost  you. 

Likewise,  in  the  large  city  it  is  sometimes  an  ad- 


LOCATION  29 

vantage  to  be  located  in  a  street  where  there  are  a 
number  of  physicians,  as  people  will  go  there  in 
emergencies,  with  the  assurance  that  they  will  find 
at  least  one  doctor  at  home.  In  the  Western  States, 
notably  Ohio,  it  is  customary  to  have  an  office  in  a 
corner  bungalow  and  to  live  in  another  part  of  the 
city.  This  has  its  advantages  for  the  one  who  is 
well  known,  but  it  is  questionable  if  it  is  profitable 
to  the  beginner.  Likewise,  in  Chicago,  the  promi- 
nent specialists  and  consultants  have  their  offices  in 
the  business  part  of  the  city  and  live  elsewhere.  The 
same  tendency  is  observable  in  New  York. 

It  is  not  always  wise  to  practise  in  the  town  where 
you  were  born  and  brought  up.  In  some  places  it  is 
a  great  advantage  to  do  so.  The  social  relations,  if 
they  are  of  the  right  kind  and  if  you  can  preserve 
your  dignity,  will  certainly  bring  a  practice  much 
earlier  than  when  you  begin  among  strangers.  How- 
ever, at  home  there  are  more  heart-burnings,  more 
unkind  criticisms,  and  it  is  questionable  whether 
you  will  make  as  loyal  patients  as  you  would  among 
strangers.  If  your  training  has  been  good,  and  you 
have  always  shown  a  clean  score,  then  I  believe  that 
you  will  more  easily  acquire  a  competence  in  a 
neighborhood  wherein  you  are  well  known.  You  will 
probably  find  collections  more  difficult  than  among 
strangers. 

In  beginning  in  a  neighborhood  you  should  look 
for  the  influential  citizens  of  your  community  and 
cater  to  their  good  graces,  taking  every  legitimate 
opportunity  that  is  offered  to  obtain  a  foothold. 


30      BUILDING  A  PROFITABLE  PRACTICE 

Never  begin  in  a  poor  locality,  nor  in  a  locality 
sparsely  settled.  If  you  want  business,  you  must  go 
where  it  is. 

Don't  settle  in  the  small  place  with  the  idea  that 
as  soon  as  you  have  saved  a  few  dollars  you  will 
move  to  the  great  city.  That  day  will  probably  never 
come,  and  if  it  does  you  will  have  lost  the  natural 
increment  of  the  years  of  waiting  and  toil.  But 
above  all  pick  out  a  place  where  you  would  like  to 
live  out  your  days.  After  all,  your  own  health  and 
comfort  should  be  the  most  important  factor  in 
your  choice.  It  is  said  of  the  physicians  of  Butte, 
that  they  live  there  only  long  enough  to  make 
enough  money  to  spend  the  rest  of  their  life  some- 
where else,  and  from  the  nature  of  the  place  I  can 
readily  believe  it. 

Once  you  locate  don't  move  about  to  another 
section  or  even  another  street,  if  you  can  possibly 
help  it,  as  every  year  in  one  house  is  in  itself  an 
increment  on  your  capital  stock,  otherwise  known  as 
reputation,  and  frequent  moving  much  impairs 
the  capital.  A  section  of  the  city  where  people  own 
their  own  homes  is  best,  because  they  are  permanent 
fixtures,  whereas  most  of  the  tenement  dwellers  move 
every  second  year. 

If  you  decide  to  locate  in  a  large  city,  unless  you 
have  a  large  circle  of  friends,  it  is  better  to  go  into 
a  tenement  quarter  or  near  one. 

A  city,  containing  a  number  of  factories  of  dif- 
ferent kinds,  makes  a  good  location  for  the  beginner. 
In  such  places,  money  is  usually  in  circulation,  and 


LOCATION  31 

if  one  class  of  work  is  slack,  there  will  always  be 
other  factories  running.  This  makes  for  ready 
money.  The  small  suburbs  of  large  centres  are  also 
good  places.  Certain  parts  of  the  country  are 
known  to  be  already  overstocked.  Southern  Cali- 
fornia is  notably  full.  So  many  physicians  have 
gone  there  for  their  health  that  it  is  currently  re- 
ported that  the  State  board  of  California  makes  the 
examination  for  license  very  difficult. 

Religion. — In  general  there  are  three  religious 
bodies  whose  members  prefer,  and  often  insist  on, 
having  a  physician  of  their  own  belief. 

(1)  Orthodox  Hebrews. — In  many  of  the  smaller 
cities  there  are  groups  of  this  race  that  will  employ 
one  of  their  own  kind,  even  though  it  inconvenience 
them  greatly. 

(2)  Koman  Catholics  also  are  apt  to  desire  one 
of  their  own,  because  they  feel  that  he  may  better 
understand  their  point  of  view.  There  are  many 
communities  of  a  thousand  and  more  members  of 
this  faith  where  there  is  no  Catholic  physician.  A 
letter  addressed  to  half  a  dozen  Bishops  ought  to  be 
the  means  of  finding  out  such  places.  In  writing 
such  letters  of  inquiry  to  anyone  always  enclose  a 
stamped  envelope  with  your  address.  Eeligious 
periodicals  may  also  take  cognizance  of  such  re- 
quests. 

(3)  Among  protestant  denominations,  the  Meth- 
odists are  more  kindly  disposed  toward  one  of  their 
own  faith.     The  same  procedure,  as  above  men- 


32      BUILDING  A  PROFITABLE  PRACTICE 

tioned,   might  be  followed   in  finding   a   suitable 
opening. 

In  commencing  practice  you  ought  to  have  at 
least  a  capital  of  about  $500 — ^$150  for  equipments, 
and  $350  to  supply  your  first  year's  deficiency.  At 
the  end  of  that  time,  in  most  instances,  you  can  make 
your  living  expenses. 


CHAPTER  .VI. 

Office. 

If  unmarried,  seek  a  room  in  a  house.  It  should 
be  on  the  ground  or  stoop  floor.  A  back-parlor  is 
commonly  chosen,  with  the  privilege  of  using  the 
front  parlor  as  a  waiting  room.  There  was  a  time 
when  physicians  rarely  opened  an  office  in  a  flat 
or  apartment  house.  Now,  that  the  conveniences  of 
the  apartment  are  so  many,  it  is  becoming  quite 
common  to  find  many  prominent  men  occupying 
such  quarters.  The  night  service  and  telephone  are 
items  that  partly  compensate  for  the  privacy  of  the 
house.  Furthermore,  many  chance-calls  come  from 
the  families  in  apartment  houses.  In  addition,  a 
large  number  of  people  become  familiar  with  your 
name,  and  you  are  talked  about  correspondingly.  I 
feel  quite  sure  that  for  the  beginner  the  apartment 
house  is  more  advantageous  than  the  private  house. 
Whether  it  is  true  for  the  one  well-established  in 
practice  is  another  matter.  If  possible,  have  run- 
ning water  in  the  office  or  near-by.  This  can  usually 
be  installed  easily  in  apartment  houses.  The  office, 
if  possible,  should  be  convenient  to  street-car  lines 
and  near  main  thoroughfares. 

It  is  better  to  begin  on  a  prominent  street  or 
avenue.  A  corner  is  better  than  the  middle  of  the 
block.  Your  object  is  to  let  people  know  that  such 
a  being  as  yourself  exists.    The  fewer  steps  to  climb 

3  88 


34      BUILDING  A  PROFITABLE  PRACTICE 

the  better.  Don't  go  on  the  same  floor  with  a  tailor, 
dentist  or  any  other  business. 

If  you  are  boarding  have  your  meals  away  from 
the  place  where  you  have  your  room.  I  say  this 
because  you  will  often  tire  of  the  food  when  you 
cannot  very  well  tire  of  the  room,  besides  eating 
in  a  boarding  house  or  restaurant  will  cause  you  to 
make  other  acquaintances  and  patients. 

Don't  tell  the  people  of  the  house  all  of  your 
business  and  don't  let  them  get  at  your  accounts, 
etc.,  because  the  time  will  come  when  you  and  they 
will  disagree  and  they  may  publish  far  and  wide 
all  that  is  derogatory  about  you.  It  is  better  if  you 
can  have  a  relative,  a  sister  or  mother,  to  keep  house 
with  you,  as  they,  through  their  conversations  with 
chance  acquaintances,  will  be  the  means  of  making 
your  presence  known  in  the  locality.  It  is  surpris- 
ing how  little  talk  of  this  kind  is  sometimes  sufficient 
to  bring  patients. 

Li  the  country  a  black  sign,  2  feet  long  by  9 
inches  high,  with  gold  letters  is  in  general  use.  In 
the  city  the  ordinary  window  sign  consisting  of 
white  glass  about  2  feet  long  and  4  inches  high  with 
black  lettering  is  in  common  use.  Have  the  sign 
read  Dr.  or  Doctor,  rather  than  M.D.  There  are  so 
many  osteopaths,  hydropaths,  opticians,  etc.,  nowa- 
days who  have  a  D.  at  the  end  of  their  title  that 
people  do  not  always  notice  the  degree. 

It  is  better  to  let  people  know  you  are  a  real 
doctor.  Physician  and  surgeon  does  not  look  well, 
and  impresses  no  one  to-day.    The  lettering  should 


OFFICE  35 

not  be  large,  and  if  the  sign  is  far  from  the  street 
be  careful  not  to  have  it  too  small.  Such  a  sign 
will  cost  about  two  dollars. 

In  the  early  days  of  your  practice  it  is  well  not 
to  have  any  office  hours  painted  on  the  sign,  because 
some  people,  on  looking  at  the  sign  and  noting  that 
the  time  is  past  your  office  hours,  will  pass  on  while 
you  may  be  anxiously  waiting  for  a  client. 

A  brass  sign  costs  about  five  dollars  and  is  a  good 
investment.  For  outside  use,  a  glass  sign  with  black 
back  and  gilt  letters  is  attractive,  but  will  often 
crack  in  cold  weather.  In  addition,  a  small  celluloid 
nameplate  on  the  door  is  generally  advisable.  The 
location  of  your  office  will  be  a  factor  in  deciding 
whether  two  or  three  signs  are  better.  In  some  local- 
ities a  lamp  burning  behind  the  window  sign  will 
bring  night  work.  Have  the  room  lighted  until 
11  P.M.  A  neatly  arranged  box  of  flowers  in  the 
window  sometimes  attracts  attention  to  the  sign. 

The  office  should  be  well  heated  in  winter.  The 
location  should  be  in  as  quiet  part  of  the  first  floor 
as  possible.  It  should  have  plenty  of  light  all  day, 
in  default  of  which  gas  and  electricity  can  be  utilized 
as  well.  In  fact,  a  large  number  of  offices  in  large 
cities  are  so  lighted. 

It  is  sometimes  an  advantage  to  let  patients  out 
without  their  having  to  pass  through  the  reception 
room.  This  feature  is  seldom  troublesome  in  the 
early  days  of  practice. 

The  size  of  the  office  is  not  of  much  concern  to 
the  beginner.   A  large  office  certainly  makes  a  better 


36      BUILDING  A  PROFITABLE  PRACTICE 

impression.  A  desk  and  three  chairs  are  absolute 
essentials  in  the  furnishings. 

A  lounge  is  almost  an  essential  and,  if  you  do 
not  care  to  buy  an  examining  table  at  once,  it  will 
serve  for  examination,  etc.  It  is  well  to  put  up  as 
many  diplomas  as  possible. 

This  may  seem  bad  taste,  but  then  you  must  re- 
flect that  you  are,  professionally  at  least,  a  stranger 
to  your  early  patients,  and  all  that  they  have  to 
recommend  them  to  trust  their  lives  in  your  hands 
will  be  the  knowledge  that  you  have  been  at  least 
trained  in  the  practice  of  your  profession  by  men 
who  have  thought  you  worthy  enough  to  sign 
their  names  to  your  diploma.  All  things  being 
equal,  the  man  who  has  graduated  from  three  good 
institutions  would  be  preferred  by  any  of  us  to  the 
man  from  one ;  and  the  patient  must  form  his  opinion 
from  what  he  sees. 

A  nice  clock  placed  in  a  conspicuous  place  is  al- 
most an  essential.  One  should  have  a  lamp  that  is 
capable  of  furnishing  light  for  a  laryngoscopic  ex- 
amination. A  student  lamp  which  can  be  raised 
and  lowered  by  a  screw  will  answer  until  there  is 
enough  work  to  make  it  pay  to  put  up  a  wall  bracket. 

A  wall  bracket  is  of  course  more  ornamental,  but 
is  not  a  necessity.  Also  a  set  of  Snellen's  test  cards, 
a  cuspidor  and  a  mirror.  This  mirror  should  be  so 
placed  on  the  wall  that  women  can  see  to  adjust  their 
hats,  etc.  It  should  be  at  least  2  feet  high  by  1 
foot  wide.  The  room  should  always  be  well  heated, 
so  that  no  feverish  patient  can  ever  say  that  he 


Compact  and  convenient  arrangement  of  desk,  card  index,  and  lights. 


OFFICE  87 

caught  cold  in  your  office  during  an  examination. 
See  that  it  is  well  aired  several  times  daily.  As  to 
furnishing  your  office  later  on  in  practice,  the  more 
luxurious  the  better. 

It  is  well  to  have  a  small  alcove  or  lavatory  for 
washing  of  hands. 

If  the  tables  are  covered  with  glass,  there  is  less 
dirt  collected,  and  they  look  clean  and  attract  atten- 
tion. A  mirror  can  be  placed  on  top,  and  it  will 
improve  the  appearance  very  much.  Have  few,  if 
any,  pictures  in  the  office;  above  all,  it  should  be 
neat  and  clean.  That  is  your  workshop,  not  a  re- 
ception room  for  social  entertainments.  Let  every- 
thing indicate  that  you  are  a  doctor,  a  doctor  only, 
first,  last  and  at  all  times.  Whatever  you  have  in 
the  line  of  apparatus,  have  it  on  view. 

It  may  seem  bad  taste  to  have  apparatus,  etc., 
on  view,  but  I  am  fully  convinced  that  the  more  vis- 
ible apparatus  you  have  the  better.  Many  people 
reason  that  the  man  with  such  things  is  better  fitted 
to  treat  them,  should  the  occasion  arise  to  make  their 
use  necessary,  than  one  without  them.  This  is  cer- 
tainly true.  If  you  do  not  have  the  apparatus  handy, 
you  will  put  off  treating  many  a  case  that  needs  such 
treatment. 

INSTEUMENTS. 

The  following  instruments  are  absolutely  neces- 
sary to  have  in  your  office : 

1  obstetric  forceps, 
1  small  soft  catheter, 


38      BUILDING  A  PROFITABLE  PRACTICE 

1  surgical  pocket  case, 

1  head  mirror, 

1  laryngeal  mirror, 

1  tongue  depressor  (spoon  will  do), 

1  applicator, 

dressing  forceps, 

curette, 

catheter, 

nasal  speculum, 

aural  specula, 

odd  size  urethral  sounds,  from  15  to  27, 

a  couple  bougie-a-boules, 

vaginal  speculum, 

a  couple  English  catheters, 

atomizer  and  solutions  for  same, 

scale  for  baby's  weight, 

fountain  syringe, 

urinary  test  set, 

hypodermic  syringe, 

rectal  tube, 

stomach  tube, 

uterine  dilator, 

1  syringe  for  antitoxin,  aspirating,  etc. 

In  addition,  as  soon  as  you  can  afford  it,  a  mi- 
croscope with  a  1/12  immersion  lens,  a  bath-room 
scale  for  weighing  adults,  a  nasal  snare,  intu- 
bation set,  tonsillotome,  nasal  forceps,  adenoid  cu- 
rette and  forceps,  corneal  spud,  placental  forceps 
and  sponge  holder,  Politzer  bag,  endoscope,  procto- 
scope and  sphygmomanometer. 


OFFICE  89 

In  your  hypodermic  case  you  should  have  at  least 
a  tube  of  the  following  hypodermic  tablets:  mor- 
phine, atropine,  apomorphine,  nitroglycerin,  and 
any  others  that  you  may  feel  are  necessary.  There 
should  be  two  needles  at  least,  because  one  may  be 
broken  or  rusty  when  urgently  needed.  When  it 
happens  that  the  needle  is  rusty,  one  can  frequently 
overcome  this  difficulty  by  filling  the  syringe  with 
water,  screwing  on  the  needle  and  then  pushing  the 
plunger  as  far  as  it  will  go.  A  match  is  then 
lighted  and  held  beneath  the  needle  until  it  is  red 
hot,  pushing  the  plunger  meanwhile.  In  a  majority 
of  instances,  the  obstruction  will  be  relieved  and 
permeation  of  the  needle  established. 

A  weighing  machine,  electrical  apparatus  of  all 
kinds,  an  X-ray  machine,  lamp  for  laryngoscopic 
work,  vibrator,  etc.,  are  each  and  all  valuable  ad- 
juncts. 

The  following  surgical  supplies  should  be  on  hand : 

1  lb.  gauze, 

1  lb.  2-inch  gauze  bandages, 

1  lb.  muslin  bandages, 

3-inch  absorbent  cotton, 

package  of  splint  wood  for  splints, 

5  yards  sterilized  gauze  or  cheese  cloth, 

antiseptic  tablets, 

a  roll  of  rubber, 

adhesive  plaster, 

set  of  pessaries, 

chloride-of-ethyl  spray, 

lamb's  wool  for  tampons. 


40      BUILDING  A  PROFITABLE  PRACTICE 

Have  a  large  daily  calendar  or  memorandum 
with  a  large  margin  on  your  desk.  You  can  make 
a  note  here  each  day  of  the  name  and  address  of 
each  patient  as  they  come  in;  also  a  list  of  all  the 
calls  of  the  day.  It  is  a  money-saving  habit  to  do 
this,  as  it  prevents  the  loss  of  names  of  office-callers, 
which  often  occurs  when  no  such  system  is  followed ; 
after  a  while  it  becomes  almost  a  second  nature  to 
write  down  the  name  of  anyone  who  calls.  Try  to 
have  a  system  in  your  office,  have  everything  spick 
and  span,  and  have  your  gauze,  tampons,  etc.,  pre- 
pared during  your  leisure  time,  so  that  no  time  will 
be  wasted  while  the  patient  is  there.  Ever>'one  will 
admit  that  the  doctor's  office  should  be  equipped  in 
the  best  possible  manner.  Impressions  are  more 
easily  made  on  a  sick  person  than  at  any  other  time, 
and  a  bare,  cheap-looking  office  is  not  calculated  to 
increase  the  patient's  confidence  in  the  ability  of 
the  doctor.  There  is  no  question  but  that  physi- 
cians in  the  past  made  a  success  with  nothing  but  a 
desk  and  prescription  pad,  and  probably  they  would 
succeed  in  a  measure  to-day  in  some  places,  but  in 
most  of  the  large  centres  the  laity  are  quite  well 
posted  and  the  doctor  is  often  judged  by  the  appear-, 
ance  of  his  office  and  his  methods. 

A  lawyer  spends  upwards  of  $2,000  for  books 
before  he  can  open  his  office;  these  are  his  instru- 
ments, and  yet  he  may  have  to  buy  many  new  vol- 
umes because  of  his  first  case.  A  cigar  store  or  no- 
tion shop  will  need  a  thousand  dollars  to  stock  it, 
before  beginning  business.     Yet  many  physicians 


OFFICE  41 

who  do  a  business  twice  as  large  are  content  to  nm 
along  with  a  very  meagi'e  equipment.  There  is 
practically  no  apparatus  in  their  oflSce,  and  they  are 
apt  to  be  disgruntled  and  sneer  sarcastically  when 
they  find  that  their  patients  have  gone  to  the  man 
who  shows  that  he  has  the  goods  to  work  with.  It 
may  be  a  professional  question  sometimes,  whether 
he  knows  how  to  get  the  best  results  out  of  his  ap- 
paratus, but  the  lajTuan  cannot,  of  course,  be  the 
judge  of  that. 

The  kejTiote  of  the  oflfice  should  be  cleanliness, 
whether  it  be  in  the  neatly  trimmed  beard  or  the 
clean  shaven  face  and  immaculate  linen. 

Smoking. — Do  not  smoke  in  your  office.  Many 
people  do  not  object  to  the  odor  of  tobacco,  but  at 
least  a  few  do,  and  those  few  may  not  come  again  in 
consequence,  while  no  one  ever  came  to  your  office 
because  it  did  smell  of  tobacco.  The  stale  odor  of 
a  pipe  is  extremely  objectionable  to  most  people, 
even  to  many  who  smoke.  A  physician's  practice 
depends  to  a  great  extent  upon  the  ladies,  and  no 
lady  ever  enjoyed  the  odor  of  stale  tobacco,  although 
a  few  may  tolerate  it. 

It  is  advisable  to  have  a  large,  flat-topped  desk 
in  the  centre  of  the  room,  and  both  day-light  and 
gas-light  in  such  a  position  that  the  light  will  shine 
on  your  back  and  on  the  patient's  face.  Your  own 
eyes  being  thus  in  the  shadow  and  his  in  the  light, 
gives  you  better  opportunity  to  observe  objective 
symptoms  and  also  gives  you  a  psychical  advantage 


42      BUILDING  A  PROFITABLE  PRACTICE 

over  him,  which  advantage  makes  him  more  likely 
to  follow  your  treatment  and  increases  his  confi- 
dence in  your  ability.  This  confidence  is  an  excel- 
lent help  in  your  treatment. 

Always  have  your  office  neat  and  clean.  Do  not 
have  refuse  cotton,  etc.,  from  the  last  patient  lying 
about  the  floor. 

THE  FOLLOWING  MEDICINES  SHOULD  BE  IN  YOUB  OFFICE : 

Aromatic  spirits  of  ammonia, 

brandy, 

Hoffmann's  anodyne, 

tincture  of  iodine, 

balsam  of  Peru, 

aristol, 

adrenalin, 

solution  silver  nitrate  (1  per  cent,  and  10  per  cent.), 

stick  of  silver  nitrate, 

carbolic  acid,  or  a  similar  preparation, 

cocaine  solution  (4  per  cent.), 

chloroform, 

rhubarb  and  soda  mixture, 

bichloride  of  mercury  tablets. 

BOOKS. 

The  only  books  that  are  absolutely  necessary  are 
your  college  text-books,  including  one  each  of  the 
specialties. 

By  all  means  subscribe  for  at  least  one  first-class 
medical  journal.    If  you  join  the  American  Medical 


OFFICE  48 

Association  (see  later)  you  will  have  one  of  the  best 
journals  in  the  world  free  of  cost.  The  books  you 
should  buy  afterwards  are  monographs  on  various 
diseases  or  a  system.  Don't  buy  any  more  text- 
books for  some  years. 

A  telephone  is  almost  as  essential  as  a  door-bell. 
Instruct  the  one  who  receives  the  messages  to  take 
the  calls  in  a  pleasing  voice  and  do  the  same  your- 
self. Nothing  is  more  aggravating  than  to  receive 
a  curt,  rasping  answer  over  a  telephone.  Always 
have  the  message  repeated,  as  many  people  forget 
their  own  address  in  the  excitement  of  telephoning. 
It  is  well  to  have  the  instrument  located  so  as  to  be 
handy  for  night  calls  in  order  that  you  will  not  have 
to  traverse  the  whole  house  to  get  to  it. 

The  attendant  who  opens  the  door  should  be 
clean  and  neatly  dressed.  A  frowsy  maid  in  a 
kimona  or  dressing  gown  is  not  calculated  to  im- 
press people. 

RECEPTION  ROOM. 

The  reception  room  should  be  pleasantly  situ- 
ated, well  lighted  and  nicely  furnished.  There  is 
much  diversity  in  furnishing  reception  rooms.  Some 
men  have  few  if  any  articles  of  furniture,  while 
others  have  it  filled  as  a  parlor. 

Personally,  I  think  the  handsomer  the  room  is 
furnished  the  better  is  the  impression  made.  One 
is  apt  to  think  that  a  poorly  furnished  or  dirty 
reception  room  betokens  similar  qualities  in  the 


44      BUILDING  A  PROFITABLE  PRACTICE 

owner  and  prejudices  the  patient  before  he  sees  you. 
Don't  allow  the  family  clothing,  such  as  coats,  col- 
lars, etc.,  to  be  strewn  on  the  floor  or  chairs;  let  it 
be  always  neat  and  clean  no  matter  what  else  you 
have  in  it. 

There  should  be  plenty  of  reading  matter,  in- 
cluding one  or  two  current  magazines,  views  of 
travels,  etc.  There  should  be  no  political  or  re- 
ligious material  on  the  wall  or  table. 

The  patient  feels  miserable  enough  when  he 
comes  in.  The  more  tact  you  display,  the  more  re- 
spect you  command.  There  should  be  nothing  in 
the  reception  room  to  suggest  what  sort  of  a  place 
it  is;  the  surroundings  should  be  bright  and  cheer- 
ful. 

Your  cards  should  be  placed  on  a  plate  in  a 
prominent  place.  In  your  absence  in  the  early  days 
of  your  practice  it  is  well  to  have  some  one  of  your 
family  come  in  from  time  to  time  to  inform  the 
waiting  patient  that  the  doctor  will  be  in  presently. 
In  every  case  they  should  usher  the  patient  in  before 
informing  him  that  you  are  not  at  home. 

If  the  patient  be  once  seated  he  will  not  so  likely 
be  in  a  great  hurry  to  leave.  A  few  judicious  words 
from  the  attendant  will  start  a  stream  of  conversa- 
tion, and  with  women  especially  such  conversation 
is  not  apt  to  lag,  and  the  time  will  not  seem  so  long. 

Never  have  the  attendant  say  that  you  are  at  a 
theatre,  place  of  amusement,  ball  game,  etc.  You 
are  always  out  on  a  call  or  business. 

There  should  invariably  be  a  definite  time  when 


OFFICE  45 

you  are  expected  home,  even  though  you  have  neg- 
lected to  fix  the  hour.  Many  a  call  is  lost  through 
the  answer,  *'  I  don't  know  when  the  doctor  will  be 
home."  Many  a  child  is  pacified  and  kept  as  a 
patient  \)j  a  tactful  presentation  of  a  cracker,  glass 
of  water,  candy,  etc.,  by  the  attendant. 

CARDS  AND  LETTER  HEADS. 

Have  printed  500  small  neat  cards  with  your 
name,  office  hours,  and  telephone  in  plain  letters. 
Sometimes  it  is  customary  to  have  the  words  morn- 
ing, afternoon  or  evening  alongside  of  the  various 
sets  of  office  hours.  The  letter  heads  may  be  dupli- 
cates of  the  card  or  your  plain  name,  without  ad- 
dress, as  your  taste  decides. 

Bill  heads  should  contain  a  duplicate  of  your 
cards,  also  state  in  plain  large  letters  the  fact  that 
this  is  a  monthly  statement  of  account,  also  a  state- 
ment that  all  accounts  are  rendered  monthly,  other- 
wise some  people  may  take  offense  when  they  re- 
ceive a  monthly  bill.  Engraved  stationery  can  well 
wait  until  the  bread-and-water  days  are  over. 

The  envelopes  should  have  your  name  and  ad- 
dress on  front  or  back. 

OFFICE  HOURS. 

It  is  better  for  a  beginner  to  have  office  hours 
at  all  times,  ready  to  receive  patients  always.  After 
you  have  some  practice,  arrange  your  office  hours 
to  suit  your  digestion,  i.e.,  meals  after  office  hours. 

It  is  the  general  custom  to  have  one  or  two  morn- 


46      BUILDING  A  PROFITABLE  PRACTICE 

ing  office  hours.  Two  hours  in  the  afternoon  and 
two  hours  at  night,  because  many  people  cannot 
come  in  until  the  day's  work  is  done. 

Morning,  Nine  to  Ten 
Afternoon,  Twelve  to  Two 

and  ordinarily  from  six  to  eight  in  the  evening, 
will  accommodate  most  people  and  will  not  seriously 
interfere  with  society  meetings,  evening  calls,  etc. 

Do  not  make  frequent  changes  in  your  office 
hours,  as  it  confuses  many  people.  Have  your  Sun- 
day office  hours  in  your  early  years  at  least  at  the 
same  time  as  on  other  days.  Many  people  can  only 
come  to  a  doctor  on  Sunday. 

If  there  are  many  physicians  in  the  neighbor- 
hood, it  may  be  well  to  have  office  hours  at  a  time 
different  from  the  others.  On  your  cards  and  pre- 
scription blanks  have  office  hours  printed  from  the 
start. 

Later  on,  it  is  a  good  plan  to  have  a  bell  to  the 
servant  from  the  office  to  let  her  know  when  to  send 
patients  in,  also  a  bell  from  the  servant's  location 
to  office  to  let  you  know  how  many  patients  are 
waiting,  so  that  you  can  economize  your  time.  The 
leading  consultants,  as  a  rule,  generally  have  a  plain 
reception  room  with  plenty  of  reading  matter  and 
occupied  by  a  typewriter,  who  in  her  spare  moments 
acts  as  office  nurse  and  book-keeper. 

It  is  customary  for  her  to  present  a  card  to  each 
patient  upon  which  he  or  she  writes  their  names, 


OFFICE  47 

or  else  does  it  on  the  typewriter.  This  is  sent  in  to 
the  doctor  as  soon  as  the  present  consultation  is 
finished. 

If  the  business  or  call  be  urgent  a  continuous 
ringing  of  the  bell  informs  the  doctor  that  he  is 
wanted  immediately. 

AS  TO  TWO  OFFICES. 

If  you  can  secure  a  room  in  a  friend's  house  in 
a  densely  populated  neighborhood,  about  a  mile  or 
so  away  from  your  own  office,  and  at  a  small  rent, 
it  may  be  well  to  open  a  second  office  there.  Have 
specified  office  hours  in  each  place. 

This  is  all  the  more  advisable  if  there  be  easy 
and  quick  transportation  between  the  two  places. 
You  will  soon  tire  of  the  proposition,  but  in  the 
meantime  you  will  have  incked  up  a  few  families 
who  will  probably  stick  to  you,  and  your  name  will 
be  more  familiar  than  otherwise.  One  of  the  worst 
things  from  a  business  standpoint  is  for  the  people 
or  physicians  to  say  of  any  doctor,  *'I  have  never 
heard  of  him." 

THE  doctor's  house. 

There  comes  a  time  in  the  life  of  most  doctors 
when  they  want  to  own  their  own  home.  This  they 
hope  to  construct  so  as  to  make  it  as  handy  and 
efficient  as  possible  from  a  business  standpoint,  and 
as  homelike  and  convenient  as  well.  There  are  al- 
most as  many  different  styles  of  doctor's  houses 


46      BUILDING  A  PROFITABLE  PRACTICE 

as  there  are  physicians,  and  the  needs  of  each  one  are 
different  from  all  others.  The  subjoined  cuts,  taken 
from  the  Journal  of  the  American  Medical  Asso- 
ciation, seem  to  cover  the  subject  of  convenience  and 
efficiency  as  well  as  any  with  which  I  am  acquainted. 


/ 


CHAPTER  VII. 

EXTBA-PRACTICE    SoURCES    OP   InCOME. 

On  the  threshold  of  practice  many  of  you  will 
feel  that  you  cannot  afford  to  get  along  without 
some  financial  aid  for  the  first  year  or  so  of  wait- 
ing for  practice.  Some  men  borrow  three  or  four 
hundred  dollars  for  this  purpose.  Others  seek  for 
an  extra-practice-means  of  keeping  the  wolf  from 
the  door.  Economy  in  all  things  will  often  avert 
these  evils. 

There  are  three  classes  of  opportunities  for  mak- 
ing a  living  in  medicine  outside  of  regular  practice, 
to  wit: 

1.  Such  as  the  government  service. 

2.  Those  which  offer  only  a  temporary  assist- 
ance, as  municipal  opportunities. 

3.  Those  that  offer  a  permanent  increase  with- 
out interfering  greatly  with  private  practice. 

Some  of  you  may  wish  to  enter  the  army  or  navy 
medical  service.  There  are  some  men  who  by  nature 
are  fitted  for  these  services ;  some  who  are  not  will- 
ing to  put  up  with  the  complaints  and  whims  of 
patients,  who  seek  a  regular  life,  one  devoid  of 
change  and  excitement  and  who  are  fond  of  the 
formality  attached  to  the  service.    Theoretically  it 

4  49 


60      BUILDING  A  PROFITABLE  PRACTICE 

is  a  fine  place  for  study,  but  thus  far  few  have 
availed  themselves  of  this  feature. 


THE  ABMY. 

The  Medical  Corps  of  the  United  States  Army 
consists  of  about  500  men.  The  vacancies  are  filled 
by  examinations.  Permission  to  appear  before  the 
board  is  obtained  by  letter  to  the  Adjutant-General 
at  Washington,  from  whom  the  necessary  blanks  and 
rules  as  to  examinations  can  be  obtained.  The  can- 
didate must  be  a  citizen  between  22  and  30  years 
of  age,  with  one  year's  hospital  experience  or  the 
equivalent  of  private  practice. 

The  examination  is  a  very  rigid  one.  It  con- 
sists of  four  parts:  (1)  the  preliminary  one  (the 
preliminary  one  includes  examination  as  to  physi- 
cal condition);  (2)  general  education;  (3)  profes- 
sional knowledge;  (4)  the  final,  following  a  course 
at  the  Army  Medical  School  at  Washington. 

The  candidate  must  be  5  feet  4  inches  in  height. 
The  eyesight  must  be  normal  or  correctable  by 
glasses.  The  general  education,  part  of  the  exam- 
ination, is  not  more  difficult  than  the  preliminary 
requirements  for  admission  to  the  New  York  medical 
schools.  The  professional  examination  is  in  writ- 
ing. Applicants  who  attain  a  general  average  of  80 
per  cent,  are  appointed  to  the  rank  of  first  lieu- 
tenant, and  are  ordered  to  the  Army  Medical  School 
for  instructions.  The  salary  commences  at  once. 
After  eight  months'  instruction  a  final  examination 


U.  S.  Army  medical  tent  with  field  equipment. 


EXTRA  SOURCES  OF  INCOME  51 

is  taken  and  a  commission  granted.  There  are  very 
few  who  fail  to  get  the  commission  after  appoint- 
ment. The  salary  amounts  to  about  $2000  per  an- 
num. Every  five  years  there  is  opportunity  for 
advancement  up  to  about  $3500  per  annum.  Med- 
ical officers  must  take  their  tour  of  service  through- 
out the  United  States  and  Philippines,  averaging  a 
year  or  two  in  each  post.  When  stationed  near 
large  cities,  there  is  opportunity  to  increase  one's 
income,  because  there  is  no  restriction  from  prac- 
tice on  the  outside  of  the  post. 

THE  NAVY. 

The  naval  medical  service  is  somewhat  similar 
to  the  army  service.  The  examination  and  promo- 
tion follow  the  same  general  course.  The  pay  is  a 
little  more.  The  naval  surgeon  has  not  the  same 
opportunities  to  increase  his  revenue  as  the  army 
surgeon.  The  latter  can  usually  make  a  snug  sum 
from  treatment  of  laymen  about  the  post  where  he 
is  stationed,  whereas  the  naval  surgeon,  except 
when  in  a  foreign  port,  seldom  has  any  such  clien- 
tele. At  the  age  of  62,  or  when  disabled,  they  are 
retired  and  receive  an  annual  pension  amounting 
to  three-fourths  of  the  pay  they  received  at  that 
time.    The  army  surgeon  is  retired  in  the  same  way. 

THE  PUBLIC  HEALTH  AND  MARINE  HOSPITAL  SERVICE. 

This  ser\dce  covers  the  duties  of  quarantine  im- 
migrant inspections,  epidemics,  national  sanitary 


52      BUILDING  A  PROFITABLE  PRACTICE 

problems,  etc.  There  are  131  medical  offices.  The 
service  is  entirely  medical. 

Candidates  must  be  between  22  and  30  years  of 
age,  graduates  of  a  reputable  medical  college,  and 
must  furnish  testimonials  from  responsible  persons 
as  to  their  professional  and  moral  character. 

The  following  is  the  usual  order  of  the  examina- 
tions:  1,  Physical;  2,  oral;  3,  written;  4,  clinical. 

In  addition  to  the  physical  examination,  can- 
didates are  required  to  certify  that  they  believe 
themselves  free  from  any  ailment  which  would  dis- 
qualify them  for  service  in  any  climate. 

The  examinations  are  chiefly  in  writing,  and  be- 
gin with  a  short  autobiography  of  the  candidate. 
The  remainder  of  the  written  exercise  consists  in 
examination  of  the  various  branches  of  medicine, 
surgery,  and  hygiene. 

The  oral  examination  includes  subjects  of  pre- 
liminary education,  history,  literature,  and  natural 
sciences. 

The  clinical  examination  is  conducted  at  a  hos- 
pital, and  when  practicable,  candidates  are  required 
to  perform  surgical  operations  on  a  cadaver. 

Successful  candidates  will  be  numbered  accord- 
ing to  their  attainments  on  examination,  and  will 
be  commissioned  in  the  same  order  as  vacancies 
occur. 

Upon  appointment  the  young  oflScers  are,  as  a 
rule,  first  assigned  to  duty  at  one  of  the  large  hos- 


EXTRA  SOURCES  OF  INCOME  63 

pitals,  as  at  Boston,  New  York,  New  Orleans, 
Chicago,  or  San  Francisco. 

After  four  years '  service,  assistant  surgeons  are 
entitled  to  examination  for  promotion  to  the  grade 
of  passed  assistant  surgeon. 

Promotion  to  the  grade  of  surgeon  is  made  ac- 
cording to  seniority  and  after  due  examination,  as 
vacancies  occur  in  that  grade. 

Assistant  surgeons  receive  $1600;  passed  assist- 
ant surgeons,  $2000,  and  surgeons,  $2500  a  year. 
When  quarters  are  not  provided,  commutation  at 
the  rate  of  $30,  $40  and  $50  a  month,  according  to 
grade,  is  allowed. 

All  grades  above  that  of  assistant  surgeon  re- 
ceive longevity  pay,  10  per  cent,  in  addition  to  the 
regTilar  salary  for  every  five  years'  service  up  to  40 
per  cent,  after  twenty  years'  service. 

The  tenure  of  office  is  permanent.  Officers  trav- 
elling under  orders  are  allowed  actual  expenses. 

For  further  information,  or  for  invitation  to 
appear  before  the  Board  of  Examiners,  address 
"Surgeon-General,  Public  Health  and  Marine- 
Hospital  Service,  Washington,  D.  C." 

The  government  positions  should  be  taken  up 
only  as  a  life  work.  Any  one  entering  the  army^ 
navy  or  marine  hospital  service,  with  the  idea  of 
remaining  there  only  a  few  years  and  then  resign- 
ing to  enter  upon  a  general  practice,  is  making  a 
grievous  error.  This  training  does  not  fit  a  man 
for  general  practice. 


64      BUILDING  A  PROFITABLE  PRACTICE 

The  private  sanatoriums,  which  are  becoming 
more  and  more  plentiful  every  year,  offer  many  op- 
portunities. Here  the  appointments  are  made  by 
the  physician  in  charge.  The  salaries  range  from 
$900  to  $2000  per  annum. 

In  the  lumber  camps  and  mining  districts  in  the 
West  and  Southwest,  physicians  are  employed.  A 
recent  graduate  can  seldom  get  more  than  $100 
per  month  at  such  work.  The  great  drawback  about 
this  institutional  work  is  the  lazy  habit  it  engenders. 
There  are  few  men  who  go  into  these  institutions 
and  who  remain  more  than  a  year  or  two  that  ever 
want  to  get  out  and  hustle  in  private  practices. 
They  become  hospitalized  and  have  no  inclination  to 
work.  Unless  you  are  physically  incapacitated  do 
not  take  such  positions. 

INSANE  HOSPITAL  SERVICE. 

Owing  to  the  great  increase  in  the  number  of 
insane  there  are  a  large  number  of  positions  open 
for  those  who  wish  to  take  up  this  field  of  work. 
It  is  a  depressing  service,  and  one  becomes  easily 
institutionalized  who  enters  this  service.  On  the 
other  hand,  there  is  little  strenuous  labor  involved 
in  looking  after  the  insane. 

In  New  York  State  there  are  more  than  a  thou- 
sand such  positions. 

The  rules  and  regulations  now  state  that  all 
oflScers  are  required  to  have  a  New  York  State 
license.    The  grades  are  as  follows : 


EXTRA  SOURCES  OF  INCOME  66 

Medical  Interne. — Salary^  $1000  per  annum  and 
maintenance.  These  officers  are  appointed  after  a 
Civil  Service  examination.  After  one  year's  serv- 
ice in  State  Hospitals  they  are  eligible  to  the  ap- 
pointment of  Assistant  Physician. 

Assistant  Physician.— Salary,  $1200  to  $1600 
and  maintenance.  Medical  internes  who  have 
served  one  year  in  State  Hospitals  and  also  those 
physicians  who  have  had  one  or  more  years  of  gen- 
eral hospital  experience  are  eligible  for  this  posi- 
tion after  examination.  When  there  are  vacant  staff 
quarters  for  married  people  the  superintendent  has 
the  discretion  to  allow  officers  of  this  grade,  who 
are  efficient,  maintenance  for  himself  and  wife. 

Senior  Physician. — Salary,  $1800  to  $2200,  with 
maintenance  for  physician  and  family.  Assistant 
physicians  are  eligible  for  the  position  of  senior 
assistant  physicians,  after  three  years'  service, 
after  taking  competitive  examination. 

First  Assistant  Physician. — Salary,  $2600  to 
$3000,  with  maintenance  for  family.  Senior  assist- 
ant physicians  are  eligible  for  this  grade  after  two 
years'  service. 

Pathologist  {First  Grade).—SalaTj,  $2600  to 
$3000,  with  maintenance  for  family.  These  phy- 
sicians are  appointed  after  a  competitive  examina- 
tion. The  grade  reserved  for  the  largest  hospitals 
and  the  commission  has  the  power  to  designate  such 
hospitals  as  shall  appoint  physicians  of  this  grade. 

Pathologist   {Second  Grade). — Salary,  $1800  to 


56      BUILDING  A  PROFITABLE  PRACTICE 

$2000,  with  maintenance  for  family.  These  physi- 
cians are  also  appointed  after  competitive  examin- 
ation and  the  grade  is  intended  for  pathologist  in 
the  smaller  hospitals. 

Medical  Inspector. — Salary,  $3500,  with  travel- 
ling expenses. 

Medical  Superintendent. — Salary,  $3500  to  $6000, 
with  maintenance  for  family. 

Superintendents  are  appointed  from  a  superin- 
tendents' list.  Only  first  assistant  physicians  and 
the  medical  inspector  are  eligible  for  the  grade  of 
superintendent.  The  examination  for  superintend- 
ent and  medical  inspector  is  usually  held  at  the 
same  time.  Superintendents  are  now  chosen  from 
the  grade  of  medical  inspector. 

All  salaries  increase  $100  per  year  from  mini- 
mum to  maximum. 

The  commission  require  that  clinical  conferences 
must  be  held  at  least  twice  a  week;  at  these  the 
various  patients  are  presented  by  the  physicians 
who  write  up  the  cases;  the  discussion  is  taken 
down  by  the  stenographer;  the  various  differential 
diagnoses  and  treatments  are  considered,  and  the 
presentation  notes  are  added  to  the  clinical  history. 

The  Psychiatric  Institute,  situated  on  Ward's 
Island,  gives  courses  of  instruction  in  nervous  an- 
atomy and  psychiatry  twice  a  year  for  those  who 
show  aptitude  for  the  work. 

Physicians  who  enter  the  service  are  at  once 
placed  upon  the  reception  ward,  where,  after  a  suit- 


EXTRA  SOURCES  OF  INCOME  67 

able  period  of  observation,  they  are  all  allowed  to 
make  mental  and  physical  examinations.  Every  effort 
is  made  to  encourage  the  men  to  interest  themselves 
in  the  work;  an  excellent  library,  containing  all  the 
literature  in  English  and  foreign  languages,  is 
available.  Those  who  have  shown  special  aptitude 
are  allowed  a  leave  of  absence  for  study  in  Euro- 
pean clinics. 

Examinations  for  the  position  of  medical  interne 
and  assistant  physician  are  held  every  few  months; 
those  for  the  higher  positions,  when  vacancies  are 
at  hand.  The  Civil  Service  list  holds  good  for  one 
year. 

With  reference  to  the  comparative  salaries  be- 
tween New  York  and  other  State  institutions  for  the 
insane,  it  may  be  stated  that  the  New  York  State 
salary  at  the  present  time  is  higher  than  any  other ; 
the  hospitals  offer  more  opportunities  for  those  who 
wish  to  engage  in  psychiatric  work  than  any  other 
State  institutions.  The  New  England  State  hos- 
pitals pay  much  less  salaries,  and  next  to  the  New 
York  State  service  the  Illinois  State  hospitals  offer 
better  opportunities  as  to  salaries  than  other  States. 

MEECHANT  MARINE. 

Some  of  you  may  for  a  time  at  least  prefer  a  life 
at  sea.  To  such  a  one  the  passenger  service  of  the 
great  transatlantic  and  coastwise  steamships  offers 
an  inviting  field.  If  you  decide  to  take  such  a  posi- 
tion, you  should  secure  a  letter  of  introduction  to 


58      BUILDING  A  PROFITABLE  PRACTICE 

the  general  agent  of  the  company  upon  whose  ship 
you  wish  to  serve.  It  is  seldom  that  you  will  be 
appointed  at  once,  but  persistence  in  calling  every 
week  or  so  will  keep  the  fact  of  your  application 
in  mind.  It  might  be  well  to  do  this  with  several 
companies.  In  the  meantime  call  on  the  surgeons 
of  other  lines  while  in  port  and  you  may  often  have 
a  chance  to  substitute.  Personal  interviews  in  such 
cases  are  absolutely  necessary.  Your  qualifications 
are  suflScient  for  any  line,  but  the  English  and  Dutch 
lines  usually  require  men  of  their  own  nationality. 

Payment  is  received  in  two  ways:  (1)  the  money 
received  from  the  company;  (2)  the  compensation 
derived  from  patients  as  an  honorarium  or,  in  vulgar 
terms,  as  a  "tip."  The  American  Line  pays  $50 
per  month ;  the  fees  may  vary  from  $25  to  $150  per 
trip,  depending  on  the  season  and  the  class  of  pas- 
sengers carried.  The  doctor  is  usually  the  close 
friend  of  the  captain  and  is  accorded  the  official 
standing  of  second  in  rank  to  the  captain.  This 
depends  largely  on  himself.  He  is  kept  pretty  busy 
during  the  whole  trip,  both  night  and  day;  in  some 
cases  making  two  hundred  visits  a  day  on  patients. 
He  dispenses  his  own  medicines  in  a  room  adjoin- 
ing his  state-room  and  is  on  duty  night  and  day. 
In  fact,  there  is  often  more  work  at  night  than  at 
day.  He  must  make  rounds  with  the  captain  each 
day. 

The  American  and  Holland-America  lines  em- 
ploy American  doctors;  some  of  the  German  lines 
will  soon  do  likewise.    The  Wilson  Line  ships  em- 


EXTRA  SOURCES  OF  INCOME  59 

ploy  American  surgeons  during  the  summer  months 
without  compensation.  Freight  steamers  which  sail 
from  port  to  port  are  sometimes  a  good  means  of 
seeing  the  world  or  of  taking  a  vacation.  Of  course, 
there  is  little  or  no  pay  for  such  service.  The 
largest  owners  of  such  transportation  steamers  are 
the  Elder  Dempster  S.  S.  Co.,  sailing  the  Royal 
African  Mail  Line  (the  office  is  at  21  Water  Street, 
Liverpool),  and  the  Hamburg- American  S.  S.  Co., 
with  offices  in  New  York  and  Hamburg.  Among  the 
other  lines  are  the  Hamburg- American,  to  the  West 
Indies,  South  and  Central  America;  Lamport  and 
Holt,  running  to  South  America ;  in  fact,  nearly  all 
of  the  large  lines  that  are  running  to  South  America. 
The  only  reason  that  should  prompt  any  of  you  to 
take  such  a  position  is  for  your  health  or  vacation. 
Ship  doctor  is  a  term  of  opprobrium.  They  usually 
become  too  lazy  to  do  any  scientific  work,  have  no 
future  and  are  very  apt  to  become  drunkards  or 
habitues.  Six  months  is  the  longest  time  that  any- 
one should  spend  in  such  service. 

To  those  of  you  who  have  an  aptitude  for  teach- 
ing and  who  remain  in  the  large  medical  centres, 
there  are  plenty  of  teaching  positions,  if  you  per- 
sistently look  for  them.  The  pay  may  be  nothing 
or  scarcely  enough  for  your  carfare,  yet  in  no  other 
way  can  any  branch  of  medicine  be  so  well  studied 
as  by  instructing  others  in  its  principles. 


60      BUILDING  A  PROFITABLE  PRACTICE 

INSUBANCE  EXAMINERS. 

The  only  insurance  work  that  is  likely  to  come 
to  you  during  the  first  year  or  two  will  be  the  so- 
called  "industrial  insurance."  These  are  small 
policies  of  from  $50  to  $200  and  the  premiums  are 
paid  in  weekly  payments.  The  examiners'  fees 
average  about  25  cents  for  each  examination.  The 
companies  doing  most  of  this  business  are  the  Metro- 
politan, the  Prudential,  and  the  John  Hancock.  The 
work  can  be  done  at  any  time  you  choose  and  is  a 
good  means  of  spending  your  idle  time.  As  there 
are  usually  many  examinations  to  be  made,  you  may 
get  your  rent  out  of  it. 

The  large  insurance  company  usually  insists  on 
an  experienced  man  who  has  an  extensive  practice. 
In  some  places,  of  course,  this  is  impossible.  The 
fees  vary.  In  the  large  cities  he  is  paid  by  salary' 
and  must  devote  at  least  two  hours  in  the  home 
office  daily,  and  in  addition  make  several  outside  ex- 
aminations. This  amounts  to  from  four  to  six 
hours  a  day.  The  salary  is  $1200  per  annum.  In 
the  outlying  districts  $600  a  year  is  paid  for  exam- 
inations. Of  course  these  out-of-town  men  do  not 
have  to  do  any  office  work.  In  many  instances  the 
fee  system  is  still  in  vogue.  The  fees  vary,  but  they 
average  about  $5  per  examination.  As  to  require- 
ments, all  companies  seek  to  get  men  who  have  had 
hospital  practice  and  who  are  in  good  standing  in 
their  local  and  State  medical  societies.  Any  other 
qualifications,  such  as  membership  in  many  learned 


EXTRA  SOURCES  OF  INCOME  61 

societies,  hospital  or  dispensary  positions,  etc.,  of 
course,  add  to  a  man's  ability,  and  consequently 
increase  his  chances  of  appointment. 

Applications. — If  the  company  has  a  medical 
referee  for  the  district  in  which  you  live,  you  should 
make  your  request  to  this  office.  It  is  his  duty  to 
keep  informed  of  the  standing  and  acquaintance  of 
physicians  in  his  territory.  If  there  is  no  referee, 
send  your  application  in  to  the  home  office  of  the 
company.  Your  request  to  receive  consideration 
must  be  accompanied  by  indorsements  of  reliable 
and  well-known  people.  Some  of  the  companies 
take  a  number  of  young  men  who  are  hospital  grad- 
uates and  train  them  up  in  the  home  office  for  a 
period  of  three  months,  working  under  the  chiefs 
of  this  department.  They  are  paid  $100  per  month. 
After  they  have  satisfied  the  management  of  their 
ability,  they  are  given  important  positions  in  the 
out-of-town  districts. 

Don't  let  any  insurance  agent  beguile  you  into 
taking  out  insurance,  with  the  bait  that  he  will  have 
you  appointed  medical  examiner  for  the  district. 
Be  sure  that  you  get  your  appointment  and  some 
work  before  taking  out  any  policy.  The  large  com- 
panies do  not  resort  to  this  method.  Fraternal  and 
lodge  insurances  usually  pay  $2  for  an  examination. 
Get  all  of  such  commissions  that  you  can. 

When  you  are  examining  an  applicant  for  ad- 
mission to  a  secret  lodge  or  fraternal  insurance  com- 
pany, after  the  routine  examination,  look  into  the 


62      BUILDING  A  PROFITABLE  PRACTICE 

nose  for  spurs,  polypi  or  enlarged  turbinates;  into 
his  ears  for  inspissated  cerumen  or  a  retracted  drum 
and  test  his  hearing.  Examine  his  rectum  for  hem- 
orrhoids, etc.,  and  if  you  are  competent  in  any 
specialty  here  is  an  opportunity  to  get  legitimate 
cases;  and  as  lodge  physicians  are  expected  to  give 
free  medical  attendance  only,  any  surgical  work 
that  is  required  will  be  paid  for  at  the  regular  rates, 
and  when  you  consider  that  almost  every  man  has 
some  trouble  with  his  nose  you  will  see  the  size  of 
your  field.  The  problem  before  you  is  simply  to  con- 
vince him  that  the  operation  is  necessary  and  bene- 
ficial, and  knowing  this  is  true  that  should  be  a 
simple  matter. 

HEALTH  DEPARTMENT  WORK. 

The  most  commonly  sought  aid  in  the  nature  of 
a  fixed  income  that  the  young  physician  looks  to  in 
the  large  cities  is  the  Health  Department.  In  New 
York  City  there  are  between  500  and  600  such  posi- 
tions. They  are  filled  from  Civil  Service  lists,  the 
result  of  competitive  examinations  that  are  held 
every  two  years.  The  only  class  to  which  you  are 
eligible  is  that  of  Medical  Inspector.  The  duties  of 
this  class  fall  in  one  of  three  or  four  classes:  (1) 
vaccination;  (2)  medical  inspection  of  all  of  the 
children  of  several  schools;  (3)  the  routine  inspec- 
tion of  communicable  diseases  in  a  certain  district; 
the  taking  of  cultures,  giving  antitoxin,  etc.  In  ad- 
dition there  are  a  few  positions  as  assistant  bac- 


EXTRA  SOURCES  OF  INCOME  63 

teriologists  and  hospital  physicians  in  the  depart- 
ment. These  positions  average  about  $100  per 
month.  The  work  requires  between  four  and  six 
hours  a  day. 

The  examinations  are  fairly  rigid  and  are  in 
writing.  Influence  counts  for  little,  as  far  as  get- 
ting on  the  eligible  list  is  concerned.  After  that, 
however,  pull  is  powerful  in  all  cities. 

Formerly  these  positions  were  easy  berths.  To- 
day the  $100  per  month  is  well  earned.  They  are  not 
conducive  to  acquiring  practice  and  should  not  be 
sought  after,  unless  after  long  trial  one  makes  a 
failure  of  general  practice.  In  small  communities 
conditions  are  somewhat  different.  There  they  do 
not  demand  much  time  away  from  practice.  No 
position  of  any  kind  demanding  several  hours  a  day 
with  a  fixed  salary  is  conducive  to  building  up  a 
practice.  You  will  rely  on  it  and  you  will  not  ex- 
ert yourself  sufficiently  to  get  private  work. 

Personal  contracts  to  take  care  of  a  family  or  an 
individual  by  the  year  are  not  often  entered  into, 
yet  there  is  nothing  unethical  in  the  procedure. 

Police  and  fire  surgeons  are  only  chosen  from 
those  long  in  practice.  There  are  only  a  few  positions 
in  the  State  service  and  in  the  street  railroad  serv- 
ices, but  they  are  not  apt  to  go  to  the  recent  grad- 
uate. Some  of  the  large  department  stores  have 
physicians  to  look  after  their  help;  such  a  position 
takes  up  about  half  of  your  time  and  pays  about 
$100  per  month. 


64      BUILDING  A  PROFITABLE  PRACTICE 

MEDICAL  JOURNALISM. 

In  all  of  the  large  medical  centres  many  a  dollar 
may  be  earned  by  arranging  with  the  editor  of  a 
medical  journal  to  spend  your  spare  time  in  making 
abstracts  of  medical  articles.  If  you  can  take  short- 
hand notes,  you  can  put  in  many  evenings  with 
profit  by  reporting  Medical  Society  Proceedings. 
The  medical  journals  receive  books  for  review. 
These  you  may  obtain  free  if  you  will  write  a 
review  of  the  work.  Annually  neat  sums  are  paid 
to  physicians  who  act  as  reporters  at  the  large  medi- 
cal meetings  for  these  journals.  This  work  does  not 
need  to  be  taken  in  shorthand. 

Work  of  the  kind  here  mentioned  is  remunera- 
tive in  more  than  one  sense.  In  no  way  can  you  get 
such  an  intimate  knowledge  of  the  idols  of  the  pro- 
fession, their  faults  as  well  as  good  traits;  at  the 
same  time  you  are  fixing  a  vast  field  of  information 
for  your  practice. 

LODGE  PRACTICE. 

The  evil  is  very  tempting  to  the  beginner.  He  is 
importuned  by  some  of  the  members  of  a  lodge  that 
this  will  be  a  good  means  of  introducing  him  to  their 
families,  that  he  will  get  the  obstetric  practice,  the 
children's  diseases,  accidents,  etc.,  together  with  the 
annual  dues.  The  introduction  is  more  seductive 
than  the  fees.  The  fees  consist  of  a  sum  varying 
from  50  cents  to  $2  per  capita  per  annum ;  $1  is  the 
prevailing  fee.    As  a  matter  of  fact,  few  men  get 


EXTRA  SOURCES  OF  INCOME  66 

much  out  of  this  line  of  work.  The  man  who  does 
succeed  would  succeed  just  as  well  without  it.  The 
people  do  not  think  they  are  getting  satisfactory- 
treatment,  no  matter  how  careful  and  conscientious 
the  doctor  may  be,  and  once  they  have  that  notion, 
nothing  will  change  their  value  of  your  services. 
They  know  you  are  cheap  and  they  will  not  trust 
their  children  to  you.  From  the  obstetric  stand- 
point, their  wives  will  have  the  same  feeling.  The 
Foresters  and  Red  Men  are  the  largest  organiza- 
tions of  that  kind  in  this  country.  There  is  nothing 
contrary  to  ethics  in  doing  this  work,  but  it  will 
never  pay  you.  The  title  lodge  doctor  will  always 
cling  to  you  and,  unless  you  are  very  hard  up  finan- 
cially, I  would  not  advise  your  taking  such  appoint- 
ments. There  are  many  grades  of  such  lodge  and 
club  practice. 

Still  lower  in  the  scale  is  the  so-called  health 
contract  insurance.  In  this  the  family  pays  10  to 
20  cents  a  month  as  an  insurance  against  illness.  In 
case  of  illness  the  doctor  will  attend  them  free.  The 
doctor  gets  10  cents  a  month  out  of  this  20  cents. 
Obstetric  cases  are  extra.  As  only  the  poverty 
stricken  take  this  up,  you  can  easily  see  where  you 
will  get  the  extra.  This  is  the  lowest  and  meanest 
of  them  all.  Do  not  under  any  circumstances  take 
up  this  work ;  rather  retire  from  the  profession  and 
go  behind  a  drygoods  counter  as  a  clerk  than 
touch  it. 


66      BUILDING  A  PROFITABLE  PRACTICE 

PATHOLOGICAL  EXAMINATIONS. 

Most  of  the  recent  graduates  in  medicine,  espe- 
cially if  they  have  had  a  hospital  experience,  are 
competent  to  do  all  of  the  ordinary  pathological 
work,  such  as  examination  of  sputa,  urine,  blood, 
tumors,  etc.  On  the  other  hand,  there  is  a  growing 
number  of  practitioners  who  feel  that  they  cannot 
satisfactorily  examine  urines,  blood,  etc.,  and  take 
care  of  their  practice.  They  may  examine  the 
urines  sent  to  them,  but  it  is  generally  in  an  imper- 
fect manner.  As  a  consequence,  there  has  been  de- 
veloped in  the  large  centres,  within  the  past  few 
years,  a  class  of  men,  not  physicians,  who,  having 
learned  the  technique  of  these  examinations,  make  a 
contract  to  do  all  of  this  pathological  work  that  is 
ordinarily  required  by  a  doctor,  for  a  lump  sum 
varying  from  $75  to  $100  per  annum.  Each  day  a 
messenger  calls  at  a  stated  hour  and  gathers  the 
specimens  and  returns  the  results  of  the  previous 
day's  examination.  Anyone  ha\ing  from  25  to  50 
doctors  on  his  list  can  make  a  nice  income  in  this 
way.  There  is  no  reason  why  you  should  not  do 
such  work;  you  are  infinitely  better  qualified  to  do 
it  than  those  who  do  it  now,  and  even  though  you 
have  only  the  work  of  a  few  men,  yet  it  will  prob- 
ably pay  the  rent,  and  you  can  make  the  collections 
and  returns  yourself,  until  you  can  afford  to  have  a 
boy  make  the  calls  after  school.  When  your  time 
becomes  so  valuable,  you  can  easily  eliminate  as 
much  as  you  choose.    If  you  do  this  work,  be  scru- 


EXTRA  SOURCES  OF  INCOME  67 

pulous,  as  an  error  on  your  part  may  mean  the  life 
or  death  of  a  patient.  Even  in  small  cities,  if  such 
a  proposition  was  placed  before  the  half  dozen  busy 
practitioners  with  a  contract  for  $50  or  $75  per  an- 
num, I  am  quite  sure  there  would  be  no  trouble  in 
securing  their  assistance.  Such  work  never  lessens 
your  status  in  the  profession,  as  many  other  forms 
of  outside  work  do ;  on  the  other  hand,  you  rise  as  a 
result  of  it. 


CHAPTER  Vin. 

The  Stabt  in  Practice, 
buying  a  practice. 

In  the  rear  pages  of  most  medical  journals,  and 
the  Journal  of  the  American  Medical  Association  in 
particular,  you  will  find  a  number  of  advertisements 
otfering  practices  for  sale.  A  number  of  agencies, 
notably  the  Echo  of  Lynn,  Mass.,  make  a  business 
of  buying  and  selling  such  practices.  Generally, 
these  practices  represent  the  labors  of  one  who,  hav- 
ing spent  a  number  of  years  in  general  practice  in  a 
small  city,  wishes  to  remove  to  a  large  centre  to  take 
up  a  specialty.  In  other  instances,  the  seller  is  in- 
capacitated and  is  forced  to  move  on  account  of  his 
health. 

Beware  of  buying  a  dead  man's  practice,  unless 
you  can  take  it  up  within  a  week  or  two  of  the  phy- 
sician 's  demise.  In  most  cases,  the  practice  includes 
the  sale  or  rent  of  the  house  or  office  with  the  fix- 
tures. In  any  case,  you  should  have  a  few  months* 
personal  introduction  by  the  retiring  physician.  It 
is  only  in  case  that  there  is  absolutely  no  competi- 
tion that  you  can  expect  to  reap  any  sum  approxi- 
mating that  received  annually  by  the  seller.  In 
small  towns,  you  need  not  expect  to  retain  more  than 
one-third  of  the  former  practice.    In  large  cities  it 

68 


THE  START  IN  PRACTICE  69 

will  not  average  more  than  one-fourth.  Even  this 
introduction  is  a  powerful  lever  in  aiding  your 
success. 

When  buying  a  practice,  make  a  hard  and  fast 
bargain  that  the  seller  must  never  again  take  up 
general  practice  in  that  city. 

PARTNEBSHIPS. 

A  partnership  between  two  men  of  honor  is  mu- 
tually advantageous.  It  requires  a  lack  of  self-im- 
portance in  both.  The  older  man  may  turn  over 
his  laboratory  work  to  you,  the  care  of  the  minor 
cases  and  the  work  of  watching  at  the  bedside  in 
important  cases.  The  training  that  you  will  get 
from  such  intimacy  cannot  be  measured,  while 
the  introduction  to  a  large  clientele,  that  you 
could  not  possibly  obtain  for  many  years,  will 
follow.  If  you  make  such  an  arrangement,  you 
must  practise  self-effacement  and  never  criticise 
the  older  partner  who  is  always  watching  for  such 
criticism.  Partnerships  are  continually  advertised 
in  the  medical  journals.  All  sorts  of  positions 
open  to  you  are  advertised  in  the  medical  journals. 
You  can  advertise  here  yourself,  if  you  do  not 
find  what  you  are  looking  for.  In  addition  there 
are  a  number  of  agencies  who  make  a  business  of 
arranging  places  for  physicians.  You  will  find 
their  addresses  in  the  rear  part  of  many  medical 
journals. 


70      BUILDING  A  PROFITABLE  PRACTICE 

SEEING   DOCTORS   IN    THE    NEIGHBORHOOD. 

Immediately  on  opening  your  office,  call  on  all 
of  the  doctors  in  the  neighborhood,  say  within  a 
radius  of  one-half  mile  or  so.  Make  a  point  of  see- 
ing them  at  their  leisure  and  tell  them  that  you  have 
started  in,  that  you  will  be  glad  to  be  of  any  assist- 
ance, and  if  they  have  any  charity  patients  that  they 
wish  you  to  take  care  of  gratis,  that  it  will  be  agree- 
able to  you;  also  that  night  calls  will  be  cheerfully 
responded  to;  that  you  are  prepared  to  do  urine 
and  bacteriological  work;  that  you  are  anxious  to 
administer  anaesthetics  for  them. 

Do  it  even  though  you  get  no  returns  for  it.  This 
talk  will  be  one  of  your  best  investments.  It  may 
not  bring  interest  for  a  year  or  more,  but  it  will 
surely  help  you. 

During  this  visit  find  out  the  fee  table  in  vogue 
in  that  particular  location.  Unless  you  are  dealing 
with  an  exceptionally  high  class  of  practitioners, 
you  will  find  the  fee  table  idealistic,  and  that  a  third 
to  one-half  less  is  gratefully  received. 


CHAPTER  IX. 

Medical.  Societies. 

During  your  calls  on  the  profession,  find  out  if 
there  is  any  medical  society  in  the  place.  Every 
large  city  has  several  and  you  will  not  have  much 
trouble  in  joining  one.  The  value  of  the  medical 
society  to  the  young  graduate  is  inestimable.  Here 
you  will  meet  your  neighbors  and  your  elders  who 
will  teach  you  wisdom.  No  profession  so  freely 
offers  the  secrets  of  the  trade — if  I  may  use  the 
term — as  ours  does  to  the  young  physician.  Be 
attentive  at  all  of  the  meetings,  no  matter  how  tire- 
some they  may  seem  to  your  young  head  just  full 
of  science.  You  will  never  attend  a  meeting  without 
learning  something.  In  almost  every  county  in  this 
country  there  is  a  county  medical  society  or  asso- 
ciation. They  are  the  constituent  bodies  of  the  State 
association.  You  should  make  an  early  application 
for  membership,  as  it  gives  you  a  standing  before 
the  people,  the  law,  and  the  profession.  There  is 
always  a  presumption  that  a  man  not  belonging  to 
the  county  society  is  not  eligible  for  membership. 

ADVANTAGES. 

You  will  in  many  instances  hear  the  leading  spe- 
cialists hold  forth.  Go  to  the  meetings,  not  only  to 
learn  but  to  break  idols.  The  men  whose  names  you 
have  idolized  as  a  result  of  readings,  you  will  often 

71 


72      BUILDING  A  PROFITABLE  PRACTICE 

find  do  not  know  more  in  some  things  than  yourself. 
It  serves  to  give  you  confidence  in  yourself,  which 
is  just  the  thing  you  begin  to  feel  the  lack  of. 

Even  if  as  student  you  have  mastered  the  med- 
ical knowledge  of  the  day,  which  is  unlikely,  you 
are  entering  a  profession  that  is  moving  forward, 
and  if  you  want  to  get  in  the  vanguard,  you  must 
associate  or  worship  at  the  feet  of  those  in  the  front 
ranks,  and  be  inspired  by  their  enthusiasm  and  as- 
sistance. These  meetings  will  make  you  broad- 
minded  and  liberal  toward  the  views  of  others.  It 
will  make  you  recognize  your  own  shortcomings  and 
the  abilities  of  others.  Here  are  fostered  study  and 
investigation  in  the  mind  of  the  young  physician, 
because  the  greatest  stimulus  to  study  and  investi- 
gation comes  from  association  with  students  and  in- 
vestigators. 

The  medical  society  is  truly  a  post-graduate 
school,  furnished  practically  free  of  cost  at  your 
own  convenience;  because  here  the  members  con- 
tinue the  education  which  was  begun  at  college.  The 
amount  of  work  done  will  depend  on  the  energy  of 
yourself  and  your  fellow-physicians,  but  the  more 
work  you  do,  the  more  you  will  get  out  of  it,  no 
matter  what  the  others  may  shirk. 

Another  reason  why  you  should  join  the  society 
lies  in  the  fact  that  it  makes  for  the  good  of  the 
profession  as  a  whole,  and  it  is  your  duty,  as  well  as 
your  profit,  to  belong  to  it.  When  some  measure 
affecting  the  medical  profession  is  before  the  leg- 
islature, one  constantly  hears  the  remark,  "the  doc- 


MEDICAL  SOCIETIES  7S 

tors  don't  amount  to  anything  politically;  if  yon  get 
together,  we  will  give  yon  anything  you  want, ' '  and 
like  phrases.  If  we  were  thoroughly  organized,  no 
legislature  would  dare  turn  out  on  the  public  men 
who  study  three  months  of  medicine,  anatomy,  or 
optics  and  grant  them  almost  the  same  privileges 
that  are  granted  you  after  four  years  of  the  hardest 
kind  of  study.  Individually,  there  is  no  profession 
whose  members  wield  so  much  influence,  yet  col- 
lectively, none  can  do  less.  If  for  no  other  reason 
than  protection  of  yourself  and  your  future  prac>- 
tice  against  future  pathies,  you  should  join  the 
county  society.  The  society  is  the  best  prevent- 
ive of  jealousy  and  piracy.  A  man  will  not  say 
harsh  things  concerning  one  whom  he  expects  to 
meet  at  a  meeting  or  dinner  in  the  near  future;  he 
will  not  do  it,  because  of  the  disagreeable  effect  that 
it  will  have  on  himself.  In  any  event,  he  will  be 
more  careful  of  his  language  than  he  otherwise  might 
be,  and  he  is  more  apt  to  give  his  brother-physician 
the  benefit  of  the  doubt.  If  there  has  been  any  just 
cause  for  complaint,  a  few  minutes'  conversation  at 
the  table  will  bring  it  to  the  surface,  and  mutual 
explanations  often  bring  about  lasting  friendship. 

MEDICAL  PAPERS,  ETC. 

After  a  longer  or  shorter  period,  the  secretary 
of  your  society  will  ask  you  to  read  a  paper.  This 
invitation  you  should  accept,  and  devote  all  your 
spare  time  to  the  presentation.  In  writing  such  a 
paper,  review  the  latest  monographs  and  systems 


74      BUILDING  A  PROFITABLE  PRACTICE 

pertaining  to  the  subject.  Consult  the  indices  of  the 
principal  medical  journals  for  the  past  four  or  five 
years,  and  if  you  have  the  opportunity  look  up  the 
Index  Medicus  and  the  Index  Catalogue  of  the  Sur- 
geon-Greneral 's  Library.  Then  talk  the  matter  over 
with  you  confreres  privately,  and  get  their  opinions. 
With  all  this  material  at  hand,  and  your  own  ex- 
perience, you  are  in  the  possession  of  material  for 
an  interesting  paper.  This  paper  may  not  set  the 
world  on  fire  by  reason  of  its  originality,  but  it  makes 
at  least  one  more  subject  that  you  know  better  than 
you  did  beforehand.  Short,  sharp,  crispy  papers 
take  better  than  the  long  pedantic  ones.  It  is  diffi- 
cult for  the  neophyte  to  avoid  showing  all  that  he 
knows,  or  all  of  the  material  that  he  conned  from 
the  text-books.  You  should  notify  two  or  three 
prominent  men  beforehand  of  the  general  scope  of 
your  paper,  with  the  request  that  they  be  present 
to  discuss  the  paper.  If  this  is  not  done,  a  very 
worthy  paper  may  fall  flat,  because  the  average  phy- 
sician may  not  be  acquainted  with  the  subject. 

In  most  medical  societies  the  length  of  the  prin- 
cipal paper  should  not  exceed  twenty  minutes. 
There  are  very  few  great  scientific  addresses  that 
cannot  be  delivered  in  that  time.  History,  from  the 
Flood  to  the  present  time,  often  takes  up  the  bulk 
of  the  paper.  This  is  unfortunate,  as  it  is  seldom 
entertaining,  and  rarely  profitable.  If  in  the  discus- 
sion of  your  paper  one  or  more  of  the  members  dis- 
agree with  you  and  seem  to  criticise  your  diagnosis 
or  treatment,  don't  feel  offended.     The  one  who 


MEDICAL  SOCIETIES  76 

takes  the  trouble  to  point  out  your  error  is  probably 
your  true  friend,  rather  than  he  who  praises  you,  at 
any  rate.  If  all  minds  were  agreed,  there  would  be 
no  use  discussing  the  matter ;  so  don 't  feel  offended, 
even  though  you  are  quite  sure  that  he  is  wrong. 
In  discussing  papers,  many  men  show  that  they  did 
not  closely  follow  the  statements  of  the  reader.  It 
is  customary  for  the  reader  of  the  paper  to  close  the 
discussion.  Make  notes  during  the  discussion  of 
any  paper,  and  always  be  well-equipped  to  answer 
questions  by  careful  collateral  reading  of  the  sub- 
ject beforehand.  After  reading  a  paper,  if  it  be  of 
any  value — most  papers  have  some  value — you 
should  offer  it  for  publication.  In  doing  so,  mail  it 
to  the  editor  of  a  medical  journal  that  you  think 
worthy;  don't  send  it  to  a  journal  subsidized  by  the 
proprietary  and  patent  medicine  people.  Most  of 
the  medical  journals  furnish  250  reprints  of  the 
article  free  to  the  author.  If  they  do  not,  it  is  usu- 
ally advisable  to  purchase  that  number  of  reprints 
for  distribution  among  medical  friends. 

In  discussing  a  paper,  avoid  such  hackneyed 
phrases  as  "We  all  listened  with  pleasure,  etc." 

On  the  other  hand,  in  presenting  a  paper  or  dis- 
cussing anything  before  the  society,  do  not  open  up 
with  excuses  of  any  kind;  that  is  always  something 
of  an  insult  to  the  intelligence  of  your  audience. 
It  is  a  fault,  common  to  beginners,  because  of  their 
modesty.  By  doing  this,  you  discredit  yourself — 
before  you  start.  State  the  facts  and  let  them  speak 
for  themselves.      Make  one  or  two  points  in  the 


76      BUILDING  A  PROFITABLE  PRACTICE 

discussion  and  don't  talk  more  than  five  minutes. 
There  are  very  few  men  in  the  profession  who  can 
keep  the  attention  of  a  society  during  a  discussion 
for  more  than  ten  minutes  unless  they  are  masters 
in  the  special  field  under  consideration.  Unfortu- 
nately, many  men  do  try  to  talk  the  subject  to  death, 
by  reporting  cases  in  the  course  of  their  discussion. 
This  is  generally  bad  form,  and  surgeons  are  the 
worst  offenders  in  this  matter.  This  is  often  put 
down  as  an  attempt  to  blow  one's  own  horn.  Don't 
hurt  the  feelings  of  any  member  by  unkind  criticism. 
If  you  think  the  paper  is  commonplace,  don't  dis- 
cuss it,  but  learn  to  talk  on  your  feet  at  every 
opportunity. 

on  PRESENTATION  OF  PATIENTS. 

Whenever  in  your  dispensary  practice  you  dis- 
cover an  interesting  case,  study  it  completely;  make 
all  the  necessary  blood  and  urine  examinations,  and 
after  you  have  it  thoroughly  worked  up,  present  it 
at  the  local  society  meeting.  If  you  do  your  work  in 
a  thorough  maimer,  with  attention  to  detail,  and 
show  that  you  know  the  subject  well,  you  will  im- 
press the  members  far  more  than  if  you  presented  a 
ponderous  paper  that  consists  of  a  compilation  of 
other  men's  work.  It  will  help  you  mentally,  and 
at  the  same  time  your  confreres  will  respect  you, 
and  your  opinion  will  receive  a  consideration  that 
your  youth  would  not  entitle  you  to.  Furthermore, 
they  will  not  be  afraid  to  hand  a  case  over  to  you, 
fearing  that  you  might  not  be  able  to  manage  it  sue- 


MEDICAL  SOCIETIES  77 

cessfully.  You  should  use  your  dispensary  and 
charity  cases  for  this  purpose,  and  this  should  be 
a  sort  of  compensation  for  their  free  treatment. 

Sometimes  you  will  have  a  case  and  not  be  able 
to  diagnose  or  treat  it  successfully.  You  can  present 
such  a  case  at  the  society  and  get  the  opinion  of  the 
best  men,  which  the  patient  could  not  possibly  have 
had  under  any  other  circumstances.  It  is  not  gen- 
erally a  wise  policy  to  bring  your  private  patients, 
unless  it  be  a  most  unusual  case,  and  then  explain 
to  the  patient  that  it  is  for  his  especial  benefit.  It 
is  customary  to  give  dispensary  and  charity  patients 
their  car  fare  back  and  forth  from  the  meeting.  In 
no  case  should  the  case  be  discussed  in  the  presence 
of  the  patient,  as  he  might  misinterpret  the  ques- 
tions asked  and  suggestions  made,  and  infer  that 
you  were  not  doing  the  most  possible  for  him.  If 
you  cannot  present  a  patient,  the  next  best  thing  is 
to  report  an  interesting  case  as  to  symptoms  and 
pathological  observation.  The  presentation  of  path- 
ological specimens  is  in  the  same  line. 

You  will  be  fortunate  if  you  do  not  meet  in  your 
early  practice  that  most  subtle  poisoner,  the  medi- 
cal cynic;  he  is  almost  always  an  unsuccessful  man 
as  well.  In  his  acid  manner  he  will  smilingly  tell 
you  that  all  of  this  hot  air — when  discussing  medi- 
cal papers — does  not  amount  to  anything;  that 
medical  societies  are  hot-air  machines;  that  there 
is  nothing  new  in  medicine ;  that  it  is  all  a  fake,  etc. 
This  prophet  does  not  really  believe  these  things,  as 
next  moment  he  belies  his  statement  by  evincing  the 


78      BUILDING  A  PROFITABLE  PRACTICE 

blindest  faith  in  the  opposite  views,  but  his  cynical 
statements  always  depress  the  beginner.  Discount 
all  such  talk;  it  is  never  uttered  by  the  successful 
men  that  you  will  meet  at  societies.  Here  you  must 
leam  to  talk  medicine,  and  do  it  at  every  opportu- 
nity. Enthusiasm  is  the  only  thing  that  makes  for 
progress.  The  only  way  to  cultivate  it  in  medicine 
is  to  talk  about  medicine  and  listen  to  medical  talk ; 
the  medical  society  is  the  best  fertilizer  for  both. 

You  will  occasionally  hear  the  remark  made  that 
all  of  this  reading  papers,  etc.,  at  medical  societies 
is  mere  advertisement.  Well,  suppose  it  is.  It  is  the 
only  ethical  advertisement  that  a  medical  man,  par- 
ticularly if  he  be  a  specialist,  can  secure.  The  first 
question  that  one  asks  himself  when  listening  to  a 
paper,  is  the  reader  honest?  Try  his  suggestions, 
and  if  they  be  found  wanting  or  grossly  exaggerated, 
you  may  possibly  forgive  his  enthusiasm.  If  this 
occurs  a  second  time,  it  kills  the  reputation  of  the 
man  as  a  sound  guide  forever  afterward  in  your 
mind.  So  that  reading  a  paper  is  a  two-edged 
weapon,  and  it  is  the  only  means  that  a  large  clien- 
tele of  physicians  can  have  of  estimating  the  abili- 
ties of  one  who  passes  as  an  authority  on  any  par- 
ticular subject.  The  man  who  writes  too  much  is 
invariably  set  down  as  mediocre.  If  the  reader  of 
the  paper  clearly  demonstrates  that  he  has  superior 
skill  and  genius,  then  we  all  want  to  find  him  just 
as  much  as  we  would  want  to  find  a  new  remedy 
or  a  new  instrument  that  would  aid  us  in  our  work. 
If  he  is  commonplace,  according  to  our  standard  as 


MEDICAL  SOCIETIES  79 

reflected  in  his  writings,  then  we  so  rate  him.  One 
commonly  calls  a  consultant,  other  things  being 
equal  or  nearly  so,  from  among  a  coterie  or  society, 
with  the  members  of  which  he  is  well  acquainted.  If 
we  know  such  men  as  brothers,  that  they  are  honest, 
that  we  can  freely  discuss  everything  with  them, 
there  is  no  hesitancy  in  meeting  them.  Favors  may 
be  asked  that  one  could  scarcely  ask  from  a 
stranger.  The  only  way  that  such  an  acquaintance 
can  be  made,  outside  of  a  medical  college,  is  in  the 
medical  society. 

If  one  is  in  need  of  assistance  in  any  place,  he 
will  call  for  aid  from  among  the  men  with  whom  he 
associates  in  the  medical  societies,  and  many  a 
young  man  has  picked  up  a  good  fee  just  through 
such  a  chance.  Likewise,  one  sends  patients,  mov- 
ing to  far-off  neighborhoods,  to  physicians  whom 
he  has  met  at  medical  meetings.  Medicine  is  in 
reality  the  most  monastic  of  all  professions.  The  doc- 
tor cannot  fraternize  with  merchants,  lawyers  or  the 
clergy;  his  language  is  different,  his  ideals  are  dif- 
ferent, he  sees  things  through  entirely  different 
glasses.  It  is  only  in  the  medical  society  that  he  can 
find  those  who  understand  his  point  of  view,  who  can 
console,  encourage  and  advise.  He  can  sit  down  at 
a  repast  after  the  meeting  and  discuss  his  difficult 
case  with  the  best  specialist  in  that  particular  line. 
Possibly  it  is  himself  who  is  ill.  How  can  he  know 
whom  to  select  as  his  medical  adviser  in  that  par- 
ticular instance  unless  he  knows  the  best  men  in  that 
line  of  work?     When  a  physician  wants  to  know 


80      BUILDING  A  PROFITABLE  PRACTICE 

whether  a  physician  in  another  locality  is  likely  to 
be  competent  or  not,  the  first  thing  he  usually  does 
is  to  look  him  up  in  the  medical  directory.  If  he 
finds  that  the  man  belongs  to  a  number  of  promi- 
nent medical  societies,  he  judges  that  it  is  more  than 
likely  that  he  is  in  good  standing  in  the  profession. 

When  you  are  asked  by  patients,  '  *  Do  you  know 
Doctor  So-and-So?"  who  had  been  their  old  family 
physician  when  they  lived  in  another  part  of  the 
city  or  county,  always  answer  **Yes."  You  can  as- 
sure them  that  he  is  a  friend  of  yours ;  this  you  can 
do  truthfully  by  saying  that  you  met  him  at  some 
society  meeting.  When  it  comes  to  the  doctor's  ear 
that  you  know  him  and  like  him,  personal  vanity 
will  make  him  all  the  more  ready  to  return  the  com- 
pliment and  perhaps  turn  cases  of  his  own  in  your 
neighborhood  over  to  you.  It  is  surprising  to  see 
how  much  the  mere  knowledge  that  you  know  a  phy- 
sician, in  whom  a  patient  has  had  confidence,  will 
suffice  to  increase  that  same  patient's  confidence  in 
yourself.  In  any  case,  not  to  be  known  by  other 
doctors  is  a  bad  thing  for  both  the  doctor  spoken  to 
and  the  one  spoken  of. 

Join  one  of  the  smaller  medical  societies  that 
meet  from  house  to  house.  In  these  small  societies 
the  little  things  that  occur  in  the  profession  will  be 
discussed  in  a  manner  that  is  impossible  in  a  large 
gathering;  aside  from  this,  the  personal  contact 
with  successful  men  and  specialists  will  give  you  a 
freedom  in  asking  their  advice  that  you  could  not 
otherwise  have.    This  is  one  of  the  results  of  the  so- 


MEDICAL  SOCIETIES  81 

cial  part  of  these  house-to-house  meetings.  The  good 
fellowship,  entertaining  stories  and  anecdotes  will 
make  you  look  forward  with  pleasure  to  each  one 
of  these  meetings.  It  is  in  societies  of  this  kind  that 
you  will  be  posted  concerning  hospital  positions; 
good  cases  will  be  referred  to  you  and  your  ser- 
vices as  anaesthetist,  microscopist,  etc.,  will  be  de- 
manded. In  less  than  two  years  your  dues  in  socie- 
ties will  be  as  1  to  10  compared  with  the  work  they 
will  bring  you.  You  cannot  lose  anything  by  going 
to  them,  as  you  can  always  be  reached  on  the  'phone 
if  there  are  any  calls. 

Here  you  will  be  more  apt  to  find  out  the  real 
fee  table  in  existence  in  the  locality,  and  you  may 
find  out  who  are  dead  beats,  undesirable  patients, 
etc. ;  also,  how  accounts  are  collected,  and  the  hun- 
dred and  one  details  of  practice. 

When  a  subject  is  announced  for  these  meetings, 
read  it  up  in  your  text-books,  and  then  go  and  see 
what  is  new.  If  you  are  an  attentive  member,  it  will 
soon  be  noticed,  and  before  many  years  have  passed 
you  will  find  yourself  an  officer  in  the  organization. 
The  offices  always  go  to  those  who  are  attentive  at 
the  meetings.  It  is  not  advisable  to  air  your  views 
in  any  of  the  societies  for  a  year  or  so,  after  which 
time  take  part  in  any  discussion  to  which  you  can 
add  anything  new  or  unsaid. 

Without  these  societies  there  is  no  way  of  bring- 
ing local  practitioners  together.  The  very  nature 
of  their  occupation  makes  them  work  alone,  and  they 
seldom,  or  never,  meet  unless  it  be  in  some  public 

6 


82      BUILDING  A  PROFITABLE  PRACTICE 

place,  as  a  cigar  store,  public  gathering,  etc.  This 
working  alone  tends  to  make  a  man  morbid.  He  feels, 
perhaps,  that  he  is  doing  better  work  than  others, 
that  other  men  would  have  had  just  as  bad  results  as 
he  himself,  and  perhaps  worse.  This  consoles  him 
in  adversity,  but  meanwhile  he  does  not  advance. 
Nearly  all  of  the  really  beautiful  friendships  and 
self-sacrificing  acts  that  one  oftentimes  finds  among 
medical  men  have  their  inception  in  meetings  of 
medical  societies. 

It  is  only  by  attending  the  meetings  of  the  med- 
ical society  that  you  can  keep  abreast  of  the  times. 
You  cannot  find  the  transactions  as  they  actually 
occur  in  any  medical  journal.  Listening  to  a  well- 
delivered  paper  and  reading  the  same  is  as  different 
as  eating  a  fresh  peach  and  a  preserved  one.  The 
discussions  start  more  trains  of  thought  than  any 
amount  of  dry  reading.  The  meeting  together  in 
medical  societies  makes  the  physicians  broad-minded 
and  liberal  toward  the  views  of  others.  It  stimu- 
lates study  and  investigation.  If  you  are  a  country 
practitioner  you  are  working  alone;  you  cannot  go 
as  the  farmer  does  in  the  evening  to  the  country 
store  and  discuss  the  events  occurring  in  your  life, 
your  cases,  etc.  On  the  other  hand,  if  you  do  not  get 
out  and  meet  your  own  caste  you  will  fall  into  the 
rut  that  has  extinguished  the  ambitions  of  so  many 
of  the  older  practitioners. 

This  coming  in  contact  with  your  neighboring 
physicians  has  many  other  advantages.  Until  the 
community  of  interests  idea  produced  systematic  or- 


MEDICAL  SOCIETIES  83 

ganization,  the  rivalry  between  local  bankers  was 
proverbial ;  now  they  are  hand  in  glove  with  one  an- 
other. Lawyers,  because  they  are  meeting  one  an- 
other daily,  have  always  had  the  reputation  of  living 
in  peace  and  plenty.  They  come  to  know  one  another, 
to  know  their  faults  and  faculties,  and  thus  have  re- 
spect for  one  another.  After  a  hard-fought  suit  the 
opposing  lawyers  do  not  look  daggers  at  one  an- 
other as  physicians  have  often  done;  on  the  other 
hand,  they  will  most  likely  adjourn  to  the  nearest 
cafe  and  discuss  the  victim  over  full  glasses. 

MEMBERSHIP   IN    THE   AMERICAN   MEDICAL   ASSOCIATION. 

As  you  are  already  a  member  of  the  State  As- 
sociation, your  next  move  will  be  to  join  the  Na- 
tional body — the  great  A.  M.  A.  with  its  40,000  mem- 
bers. The  cost  of  this  is  $5  per  annum,  for  which, 
in  addition  to  membership,  you  receive  the  best 
weekly  medical  journal  in  the  world.  To  join  thig 
body  it  is  necessary  for  you  to  be  already  a  member 
of  your  local  county  society. 

The  meetings  of  this  body  are  held  in  different 
sections  of  the  country  each  year,  usually  in  the  first 
week  in  June,  and  are  open  to  all.  Here  are  gath- 
ered many  of  the  leading  lights  and  general  practi- 
tioners from  all  over  the  country.  The  scientific 
work  is  divided  into  eight  sections.  In  these  eight 
different  halls  there  will  be  discussed  the  progress 
of  the  past  year  in  the  different  specialties,  as  well 
as  in  medicine  and  surgery.  At  night  recreation  is 
furnished  to  all.    The  money  spent  in  attending  one 


84      BUILDING  A  PROFITABLE  PRACTICE 

of  these  meetings  will  be  well  repaid  before  the  year 
is  over. 

In  New  York  State  the  State  Medical  Society  un- 
dertakes to  defend  its  members  in  case  of  suits  for 
malpractice,  provided  that  the  member  is  not  grossly 
culpable.  After  six  years  there  has  not  been  a  ver- 
dict obtained  in  any  case  where  the  society  defended 
the  suit.  In  addition  most  State  societies  furnish 
you  with  a  fair  monthly  medical  journal  and  in  ad- 
dition a  medical  directory  is  distributed  in  this  and 
adjoining  States.  Membership  in  State  and  county 
societies  in  New  York  with  all  of  these  privileges  is 
only  $6  a  year. 

REFERENCE   BOOKS. 

"Methods  and  Benefits  of  Medical  Organization,"  J.  N. 
McC!ormack. 

"  The  Organization  of  the  Medical  Profession,"  George  H. 
Simmons. 


CHAPTER  X. 

The  Office  Call. 

When  a  patient  is  ushered  into  the  office,  re- 
ceive him  or  her  cordially.  A  hearty  hand-grip,  with 
a  welcome,  especially  if  you  can  call  the  patient  by 
name,  whether  you  have  been  previously  introduced 
or  not,  puts  the  patient  at  ease  and  impresses  him 
with  the  feeling  that  you  are  personally  interested 
in  him.  After  closing  the  door,  point  to  a  seat. 
Then  ask  his  name  and  address;  write  these  data 
down  at  once.  If  he  is  consulting  you  for  the  first 
time,  it  is  well  to  allow  him  to  tell  his  story  in  his 
own  way.  Sometimes  there  is  a  hiatus  between  his 
entrance  and  the  commencement  of  his  story,  which 
may  be  slightly  embarrassing,  but  a  few  remarks 
about  the  weather,  etc.,  will  bridge  it  over.  After 
he  has  recited  his  story  take  a  methodical  history  of 
the  patient;  and  you  should  have  a  systematic  way 
of  doing  this,  even  though  you  abridge  it  later, 
when  you  are  busy.  This  history-taking  impresses 
the  patient  that  you  take  a  deep  interest  in  his  case. 

HISTORY-TAKING. 

If  you  are  to  be  systematic  in  your  habits,  I  can 
strongly  recommend  the  use  of  the  card  index  in 
your  history  work.  You  should  begin  to  take  his- 
tories of  all  the  cases  that  you  see  now  in  your 
clinics  and  keep  them,  comparing  them  with  the  text- 

85 


86      BUILDING  A  PROFITABLE  PRACTICE 

book's  description  of  the  disease.  You  should  make 
and  keep  accurate  notes  of  every  case  you  see  in  a 
dispensary  or  hospital  practice.  This  is  one  of  the 
best  forms  of  study  and  will  be  of  incalculable  bene- 
fit, because  of  the  careful  habit  it  engenders.  Every- 
thing in  your  future  practice  depends  on  the  habits 
you  form  at  the  beginning,  and  of  all  habits,  next 
to  collecting  your  accounts,  the  habit  of  accurate 
history-taking  and  recording  is  the  most  important. 

Note  every  symptom,  every  effect  of  the  medicine, 
everything  that  the  patient  complains  of,  even 
though  you  in  your  superior  wisdom  deem  it  only  a 
nervous  symptom.  You  will  be  surprised  in  later 
years  what  a  fund  of  valuable  information  you  will 
have  gathered,  and  when  you  come  to  do  any  literary 
work  or  to  speak  on  any  subject  you  will  be  for- 
tified by  a  wealth  of  material  that  will  startle  your 
colleagues.  Any  stiff  blank  cards  will  do  as  the 
basis  of  your  card  index;  some  men  have  the  ac- 
counts on  one  side  and  the  history  on  the  back.  The 
recording  of  one's  cases  is  the  only  means  of  con- 
veying to  future  generations  the  results  of  your  ob- 
servations. Remember  that  your  observations  will 
be  different  from  those  of  any  one  gone  before,  be- 
cause every  case  is  somewhat  different  from  an- 
other, and  in  any  case  they  are  of  real  value. 

For  the  time  being  forget  everything  else  and 
focus  your  thoughts  on  the  patient.  By  that  very 
act,  whether  it  be  psychotherapy  or  not,  you  will 
have  done  much  to  help  the  patient  by  arousing  in 
him  the  will  to  help  himself.    While  giving  your  in- 


THE  OFFICE  CALL  87 

stnictions  to  the  patient,  endeavor  to  look  the  pa- 
tient in  the  eye.  Tom  Lawson  says :  * '  When  a  man 
is  trying  to  sell  you  something,  never  let  him  look 
you  in  the  eye;  when  you  want  to  sell  a  man  any- 
thing, fix  his  eye  with  your  own  and  the  sale  is  half 
made."  By  doing  this  you  will  more  fully  impress 
the  importance  of  your  directions  than  by  a  far-away 
gaze.  In  your  history-taking,  much  tact  must  often 
be  employed,  if  you  wish  to  get  at  the  truth. 

In  asking  disagreeable  questions,  it  is  well  not 
to  embarrass  your  patients  by  staring  at  them; 
otherwise,  they  are  apt  to  lie,  not  intentionally,  but 
because  of  confusion.  Don't  ask  a  nervous  woman, 
"What  did  your  father  and  mother  die  of?" 
Bather  say,  "What  disease  did  your  parents  suffer 
from?"  etc.  After  taking  an  accurate  history,  it  is 
good  practice  to  write  it  down  at  the  time,  as  it  im- 
presses the  patient  that  you  are  interested  in  him. 
You  are  now  ready  for  the  examination.  As  a  pre- 
liminary to  any  physical  examination,  take  the  tem- 
perature, pulse  and  respiration  of  every  patient.  It 
will  often  put  you  on  the  right  track  as  to  the  cause 
of  the  trouble.  At  the  same  time  it  gives  you  time 
to  collect  your  thoughts  for  the  next  questions. 

THE  EXAMINATION  OF  THE  PATIENT. 

Examine  every  patient  that  comes  into  the  oflSce. 
If  there  is  the  slightest  possible  excuse  to  do  so,  tell 
him  to  take  off  his  garments  and  listen  to  the  bare 
chest.  It  is  for  your  own  experience  as  well  as  for 
his  benefit. 


88      BUILDING  A  PROFITABLE  PRACTICE 

You  cannot  listen  too  often  to  the  bare  normal 
chest.  Some  few  will  demur  at  the  trouble  of  un- 
dressing, but  they  will  be  infinitely  more  satisfied 
afterwards,  and  when  you  get  a  reputation  for  thor- 
oughness many  normal  patients  will  come  to  you, 
simply  to  be  examined.  With  young  girls  you  must 
not  insist  too  much  on  this  naked  examination,  espe- 
cially if  there  is  no  serious  chest  trouble  appre- 
hended. Do  not  make  vaginal  examinations  on 
young  girls  unless  they  have  been  under  your  treat- 
ment for  some  time,  and  then  only  in  the  presence  of 
their  mother  or  guardian.  Such  examinations  are 
very  rarely  necessary,  are  never  pleasant  and  are 
seldom  followed  by  any  satisfactory  results.  A 
rectal  examination  will  generally  suffice.  The  ab- 
domen should  be  inspected  in  all  cases  of  stomach 
complaints.  Never  put  your  cold  hand  on  the  ab- 
domen. If  your  hand  is  not  very  warm,  place  a 
sheet  between  it  and  the  skin.  In  examining  the  ab- 
domen of  a  woman,  throw  a  sheet  over  the  patient 
and  draw  the  clothes  up  under  it,  so  as  not  to  ex- 
pose the  limbs  and  genitals.  Examine  the  heart 
while  the  patient  is  erect  and  also  while  lying  on  the 
back.  A  macular  eruption  frequently  appears  on 
the  bare  chest  of  young  nervous  women  during  the 
examination.  It  is  called  the  "doctor's  rash."  It 
has  no  significance.  In  making  a  vaginal  examina- 
tion, always  have  your  patient  get  on  the  chair  or 
table  with  the  legs  flexed  and  feet  on  the  stirrups. 
Throw  a  sheet  over  the  patient's  legs  before  raising 
the  clothing  and  then  tuck  it  around  the  legs  and 


THE  OFFICE  CALL  89 

buttocks.  Many  patients  desire  to  have  their  faces 
covered  during  the  examination.  They  can  pull  the 
sheet  up  for  this  purpose.  It  is  well  to  keep  the 
patient's  attention  diverted  while  you  are  inserting 
the  well-oiled  finger,  by  asking  her  whether  she  is 
constipated,  sleeps  well,  etc.,  at  the  same  time  as- 
suring her  positively  that  you  will  not  hurt  her  in 
the  least  degree. 

When  measuring  the  length  of  the  limb  of  a 
female  or  in  case  of  an  operation  on  a  woman,  cover 
the  vagina  with  a  folded  towel.  This  may  seem  of 
little  importance,  but  it  gives  you  the  reputation  of 
not  unnecessarily  exposing  the  genitals.  This  means 
much  to  many  women. 

When  examining  the  chests  of  unmarried  women 
or  girls  preserve  a  serious  mien.  In  all  such  cases 
manage  to  keep  the  nipple  covered  and  expose  as 
little  of  the  breast  as  possible.  Many  of  these  pa- 
tients are  almost  as  timid  of  exposure  of  the  breasts 
as  they  are  of  the  genitalia. 

Always  look  in  the  throat  of  every  child,  no  mat- 
ter what  the  complaint  may  be,  and  do  this  at  every 
examination.  In  examining  the  throat  of  children, 
the  use  of  a  teaspoon  is  less  terrifying  than  a  tongue 
depressor  and  is  equally  serviceable.  In  most  cases 
the  ears  of  children  should  be  inspected.  Examine 
and  treat  locally  if  possible  all  parts  wherever  the 
patient  complains.  Never  laugh  at  the  suggestion 
of  the  mother  that  it  is  the  teeth,  etc.;  take  every 
suggestion  seriously  and  see  if  there  is  any  founda- 
tion for  it. 


90      BUILDING  A  PROFITABLE  PRACTICE 

After  sixty  years  of  practice  the  Nestor  of 
American  Medicine  says  that  nearly  all  of  his  mis- 
takes have  been  due  not  to  lack  of  knowledge  but  to 
lack  of  thorough  examination,  and  all  of  us  can 
confirm  such  a  statement.  In  the  office  devote  all 
of  your  time  to  the  patient  under  observation. 
Don't  pick  up  letters,  books,  etc.,  and  look  at  them 
while  talking  to  the  patient  or  while  taking  the  tem- 
perature. Don 't  talk  to  his  friends,  if  they  are  with 
him,  on  other  subjects.  Look  at  him  and  give  him 
all  of  your  time  and  attention.  The  only  drawback 
to  this  thorough  examination  is  the  element  of  time. 
In  your  early  practice  this  will  seldom  bother  you, 
and  if  you  have  not  the  time  let  the  patient  dress 
and  undress  in  another  room  while  you  are  examin- 
ing another  patient.  A  stethoscope  always  im- 
presses a  patient  more  than  the  naked  ear,  and  it  is 
generally  more  satisfactory.  Older  men  discard  it 
sometimes  on  account  of  the  trouble  involved  in  its 
use.  When  you  are  so  busy  and  independent,  you 
may  do  so.  It  is  especially  of  value  in  examining 
the  chests  of  children  and  young  girls.  The  thor- 
oughness of  his  examination  is  the  reason  that  the 
city  physician  is  so  much  more  highly  respected  than 
many  of  his  country  brothers,  who  may  instinctively 
know  that  all  of  this  examination  is  not  absolutely 
necessary  in  every  instance ;  but  intelligent  patients 
do  not  have  much  confidence  in  inspective  diagnosis. 
More  than  that,  thorough  examination  begets  care- 
ful habits. 

If  you  are  in  a  great  hurry,  don't  let  the  patient 


THE  OFFICE  CALL  91 

see  that  you  are  pressed  for  time ;  take  his  pulse  and 
listen  to  his  chest  while  you  have  the  thermometer 
in  his  mouth.  After  finishing  your  examination,  do 
not  sit  down,  so  as  to  in\ite  a  lengthy  conversation. 
If  for  any  reason  a  satisfactory  examination  can- 
not be  made  in  child,  virgin,  etc.,  do  not  become  dis- 
gusted, telling  the  people  that  it  is  impossible  to  ex- 
amine such  a  one,  etc.  If  you  do,  they  will  very 
likely  go  to  one  who  will. 

Do  the  best  you  can  and  state  the  results  and 
mention  that  you  will  have  to  observe  the  case  again 
before  giving  a  positive  opinion.  The  next  time 
you  will  probably  be  more  successful. 

In  such  troublesome  cases  it  is  advisable  to  have 
other  children  taken  out  of  the  room  while  you  are 
attempting  the  examination,  as  these  children  will 
otherwise  remember  you  ever  afterwards  as  an 
ogre.  Manage  most  city  children  over  5  years  of  age 
as  though  they  were  adults;  talk  directly  to  them. 
In  that  way  you  may  gain  their  confidence,  which 
in  this  country  means  that  of  the  entire  household. 
The  same  thing  applies  to  treatment.  Never  ad- 
minister nauseous  mixtures  to  a  child.  A  placebo 
would  be  better,  as  these  children  seldom  will  take 
an  unpleasant  mixture.  The  success  of  the  homoeo- 
path with  children  rests  largely  on  the  recognition  of 
this  principle.  Always  keep  in  mind  the  natural 
tendency  to  recovery,  especially  in  children.  After 
examining  the  patient  tell  him  to  put  on  his  cloth- 
ing and  to  sit  down.  In  the  meantime  you  can 
write  out  your  directions  as  to  diet,  medicine,  etc. 


92      BUILDING  A  PROFITABLE  PRACTICE 

When  completed,  make  your  diagnosis  to  the  pa- 
tient as  far  as  yon  can,  avoiding  prognosis  unless 
you  are  pretty  certain  of  it.  Then  detail  the  diet, 
doing  this  is  writing.  It  is  seldom  that  more  than 
two  prescriptions  should  be  ordered.  If  you  cannot 
make  a  certain  diagnosis,  say  that  an  examination 
of  urine  or  blood  is  necessary  to  complete  the 
diagnosis,  and  tell  him  to  send  the  urine  with  his 
name  and  address  the  following  day;  he  can  call 
at  a  later  period.  In  this  way  you  will  have  a 
chance  to  see  him  twice  and  to  receive  some  com- 
pensation for  the  trouble  you  have  taken.  As  soon 
as  you  have  finished  talking,  give  him  his  prescrip- 
tion and  rise  to  signify  that  the  consultation  is  com- 
pleted. In  almost  all  medical  cases  it  is  good  prac- 
tice to  tell  the  patient  to  consult  you  again.  If  he 
is  entirely  well,  the  chances  are  that  he  will  not  call. 
If  he  is  otherwise,  and  he  does  not  call,  you  cannot 
be  blamed,  since  he  did  not  follow  your  advice. 
Should  he  come  back  and  be  entirely  well,  look  him 
over  and  give  him  a  tonic  or  some  general  direc- 
tions, so  that  he  does  not  feel  that  his  visit  has  been 
useless.  Do  not  tell  such  a  patient  to  drop  in,  or 
''let  me  know  how  you  are,"  but  tell  him  to  consult 
you  or  call  again.  It  is  the  custom  of  many  physi- 
cians to  escort  the  departing  patient  to  the  door 
and  bow  him  out. 

During  a  consultation  at  the  home  or  office  you 
will  often  be  asked  to  give  something  for  ''Mag- 
gie *s  cold  "  or  "  Willie 's  headache. ' '  The  parents  do 
not  expect  to  pay  you  anything  for  these  minor  com- 


THE  OFFICE  CALL  93 

plaints.  If  the  patient  is  not  there,  give  the  pre- 
scription, but  if  he  be  in  the  room  never  neglect  to 
examine  him  as  thoroughly  as  possible,  even  though 
you  cannot  collect  a  cent  for  it.  You  can  at  least 
save  your  reputation  or  mayhap  make  one  for  care- 
fulness. It  is  more  than  likely  that  you  will  find 
something  more  serious  than  that  complained  of  by 
the  guardian,  and  they  will  be  thankful  and  you  will 
be  compensated  by  the  extra  visits.  Many  people  like 
to  minimize  the  illness  of  those  under  their  care 
when  consulting  you,  because  they  do  not  wish  to  ex- 
aggerate it.  Hasty  prescribing  to  gratify  this  whim 
is  responsible  for  many  grievous  errors  and  you  will 
be  blamed  as  much  as  though  you  had  been  specially 
consulted  for  this  supposedly  minor  complaint. 


CHAPTER  XI. 

FiBST  Visit. 

Now  let  us  suppose  that  you  have  received  a  call 
to  go  to  see  a  patient.  Go  immediately,  if  you  can. 
Never  delay  with  the  idea  of  impressing  patients 
that  you  are  busy.  Sick  people  appreciate  prompt- 
ness above  all  things.  Take  your  emergency  bag 
with  you.  In  this  you  should  have,  at  the  very  least, 
the  following-named  articles :  A  small  bottle  of  aro- 
matic spirits  of  ammonia,  another  of  Hoffmann's 
anodyne,  a  pocket  surgical  case,  sterilized  bandages, 
chloroform,  dusting  powder,  a  bottle  of  antiseptic 
tablets,  a  little  absorbent  cotton,  and  a  small  cath- 
eter. You  can  put  in  as  much  more  as  you  see  fit, 
but  these  things  you  should  have,  at  any  rate.  Your 
hypodermic  case  can  always  be  carried  in  your  vest 
pocket,  and  your  stethoscope  in  the  coat  pocket.  In 
your  obstetric  satchel  you  will  need  the  following 
essentials : 

1  pair  obstetric  forceps, 
needles  and  needle  holder, 
sutures, 

antiseptic  tablets, 
douche  bag, 

2  ozs.  chloroform, 
2  ozs.  ergot, 

1  or  2  gauze  sterilized  bandages. 

94 


FIRST  VISIT  95 

A  small  baby  scale  is  of  advantage.  You  may 
carry  as  many  other  things,  such  as  gloves,  sterilized 
gauze,  etc.,  as  you  deem  necessary,  but  the  above- 
named  articles  are  essentials. 

The  proper  entrance  into  a  sick  room  is  a  fine 
art.  Some  men  have  achieved  a  great  part  of  their 
reputation  by  this  act  alone.  Probably  in  the  past 
it  counted  for  more  than  it  does  at  present;  yet  the 
ability  to  come  into  the  patient's  room  and  make 
every  one  feel  at  ease,  to  put  them  in  good  humor 
as  a  preliminary  to  inspiring  confidence,  is  a  factor 
by  no  means  to  be  despised.  It  is  an  art  that  some 
can  never  attain.  At  least,  try  not  to  be  brusque 
on  your  first  visit.  Always  take  off  your  overcoat, 
hat  and  gloves,  and  take  a  chair ;  sitting  on  the  edge 
of  the  bed  at  the  first  visit  does  not  appear  seemly. 

If  the  call  be  an  ordinary  one,  after  the  usual 
greeting  and  hand- shaking,  you  will  say  something 
like  this  ''Well,  are  you  the  sick  patient!"  etc. 
Then  the  patient  will  begin  to  tell  his  story.  After 
a  complete  history,  you  will  proceed  with  the  exam- 
ination. Be  sure  that  the  windows  are  closed.  If 
any  exposure  is  necessary,  see  that  there  are  no  cur- 
tains wide  open,  allowing  the  neighbors  to  look  in. 
Then  always  take  the  temperature,  pulse,  respira- 
tion. This  will  give  you  time  to  think  of  the  possi- 
bilities. Inspect  the  tongue  and  inquire  after  the 
bowels,  after  you  have  completed  the  examination. 
Don't  neglect  to  wash  your  thermometer  in  the  pres- 
ence of  the  patient,  both  before  and  after  you  take 
the  temperature.    One  often  takes  the  temperature 


96      BUILDING  A  PROFITABLE  PRACTICE 

before  proceeding  with  the  rest  of  the  examination. 

When  called  to  see  a  child  do  not  forget  that 
your  coming  has  probably  been  used  as  a  threat,  not 
as  a  promise,  and  naturally  the  child  is  in  dread  of 
you.  Refuse  to  be  the  "bogey  man"  for  your  neigh- 
borhood. 

Before  entering  the  room  in  which  the  sick  child 
is  lying,  ascertain  his  name — his  pet  name,  if  he  has 
one — whether  he  is  shy  or  not,  also  gather  all  infor- 
mation you  can  about  the  trouble  from  his  mother. 
Then  see  the  patient ;  if  asleep,  examine  all  you  can 
before  you  wake  him,  and  when  that  is  done  let  it  be 
done  by  the  mother  so  he  will  not  be  frightened. 
Call  him  by  his  pet  name  and  hold  his  hand,  if  pos- 
sible. If  necessary  to  take  the  temperature,  use  the 
axilla  if  the  child  objects  to  a  rectal.  Do  not  be 
gruff.  In  examining  the  throat,  get  the  child  in 
such  a  position  that  you  can  see  immediately  he 
opens  his  mouth.  If  you  have  to  push  or  pull  him 
around  with  a  spoon  in  his  mouth,  he  naturally  will 
object. 

After  you  have  finished  the  examination,  go  out 
and  wash  your  hands.  While  doing  this,  you  will 
have  an  opportunity  to  make  up  your  mind  what 
you  will  say  to  the  patient  and  friends  and  how  much 
you  will  charge  them.  Then  come  back  and  sit  down 
and  explain  what  the  trouble  is  and  the  outlook  as 
far  as  possible.  Make  it  generally  favorable  to  the 
patient.  If  you  have  any  gloomy  prognostications, 
make  them  to  the  friends,  far  away  from  the  sick 
room,  as  sick  people  have  notoriously  long  ears. 


FIRST  VISIT  97 

Now  do  not  think  for  a  moment  that  always  or  even 
in  a  large  majority  of  cases  will  it  be  easy  for  you  to 
make  a  diagnosis  the  first  time  you  see  a  patient.  A 
well-known  clinician,  writing  recently,  states,  after 
long  observation  in  one  of  the  best  hospitals  in  the 
world,  that  60  per  cent,  of  correct  diagnoses  is  the 
best  that  can  be  expected,  even  under  the  most 
favorable  circumstances.  The  class  of  diseases  that 
you  have  learned  from  your  text-books  are  only  type 
cases;  all  cases  differ  somewhat  from  them — some 
more,  others  less.  Don 't  think  that  all  of  your  pneu- 
monias, for  instance,  will  start  with  chill,  or  that 
your  appendicitis  cases  will  commence  with  pain  in 
the  right  iliac  region.  So  don't  be  discouraged  if 
you  cannot  make  an  exact  diagnosis  at  once — at 
least  you  can  treat  symptomatically.  But  what  are 
you  going  to  say  to  the  patient  ? 

Unfortunately  people  will  expect  a  young  man  to 
make  a  diagnosis,  while  the  older  physician  will  get 
away  without  making  one.  Whether  it  is  due  to 
the  mental  condition  of  the  beginner  that  makes 
him  feel  called  on  to  make  a  diagnosis  or  not  is  a 
question.  It  is  better  to  make  a  double  diagnosis 
when  in  doubt,  and  at  a  later  period  drop  one  of 
the  diseases,  if  necessary.  Your  early  patients  will 
demand  a  diagnosis  absolutely  and  will  not  have 
confidence  in  you  if  you  say  frankly  that  you  do  not 
know  what  ails  them.  Sometimes  you  can  say  it 
will  be  necessary  to  examine  the  urine  before  stating 
positively  whether  there  is  anything  else  the  matter. 
This  appeals  to  most  people.    You  must  resort  to 

7 


98      BUILDING  A  PROFITABLE  PRACTICE 

these  measures,  because  it  is  absolutely  impossible 
in  many  cases  for  anyone  to  make  a  diagnosis  at 
the  first  visit.  For  instance,  if  in  doubt  as  to 
whether  the  patient  has  pleurisy  or  pneumonia,  you 
can  say  that  he  has  both  diseases,  as  this  is  literally 
true  in  many  cases.  When  you  have  decided  which 
is  the  predominant  disease  present  you  can  empha- 
size it.  If  in  doubt  between  typhoid  fever  and  pneu- 
monia, many  practitioners  will  diagnose  typhoid 
pneumonia,  dropping  one  or  the  other  as  the  diag- 
nosis clears  up.  Likewise,  typhoid  malaria  is  a 
convenient  refuge.  Of  course,  these  terms  have  no 
such  meaning  to  you  or  to  your  colleagues.  If  you 
have  the  ability  to  paint  a  picture  of  the  disease  in 
terms  understandable  to  the  patient,  you  will  have 
a  great  advantage  in  gaining  confidence.  This  art 
you  should  cultivate.  If,  for  instance,  you  are  called 
to  a  case  where  you  are  in  doubt  as  to  whether  the 
patient  has  pleurisy  or  pneumonia,  you  may  ex- 
plain that  a  pleurisy  is  like  an  inflammation  or  sore 
on  the  skin  of  the  hand,  that  every  time  it  is  moved, 
as  in  breathing,  it  hurts.  That  sometimes  it  goes 
deeper  and  involves  the  lung,  as  the  inflammation  on 
the  hand  may  go  deeper.  When  it  does,  this  is  called 
pneumonia.  This  figure  is  not  pathologically  correct ; 
but  you  cannot  teach  correct  pathology  in  a  few  min- 
utes. You  must  fit  it  to  the*  intelligence  of  your 
patient.  The  figure  of  the  sore  finger  healing 
quickly  when  at  rest  and  scarcely  ever  when  moving 
about,  will  be  the  means  of  keeping  many  a  sick 
man  from  getting  out  of  bed  and  going  about.  When 


FIRST  VISIT  99 

he  is  suffering  from  a  disease  with  fever,  many  other 
figures  will  suggest  themselves.  The  uric  acid  crys- 
tals circulating  in  the  blood  impinging  on  nerves  is 
one  of  the  effective  standbys  of  the  irregulars.  Con- 
stitutional eczemas,  gout,  etc.,  can  be  described  as 
similar  to  putting  bad  coal  in  a  furnace;  as  a  con- 
sequence,  there  are  plenty  of  cinders  and  poor  com- 
bustion. The  eczema  is  nature's  effort  to  throw  off 
the  cinders.  You  should  have  many  such  figures  of 
speech  on  the  tip  of  your  tongue. 

It  is  impossible  for  you  to  convey  an  idea  of  the 
exact  pathological  conditions  to  anyone  who  has  not 
had  a  thorough  understanding  of  medicine,  so  you 
must  resort  to  these  figures,  always  taking  care  to 
point  out  that  it  is  somewhat  different,  but  that  you 
will  give  them  an  idea  of  the  disease.  As  you  grow 
older  and  have  a  very  intelligent  class  of  patients, 
you  may  talk  to  them  in  a  more  exact  manner.  Most 
of  the  language  of  the  average  consultant  in  a  tene- 
ment house  shoots  over  the  patient's  head.  The 
hearers  catch  a  word  here  and  there,  as  neuritis  or 
some  other  ''itis"  which,  unless  one  be  cautious, 
they  will  make  out  to  be  the  only  **itis"  with  which 
they  themselves  are  familiar.  Likewise,  do  not  use 
pathological  terms,  as  degenerations,  etc.,  or  you  will 
be  misunderstood.  As  far  as  possible  use  Anglo- 
Saxon  words  and  bring  the  disease  name  and  picture 
as  near  as  possible  to  the  level  of  your  clientele.  A 
cold  is  an  inflammation ;  a  neuritis  is  seldom  under- 
stood by  a  tenement  dweller.  Bright 's  disease  is 
more  intelligible  than  nephritis.    A  murmur,  endo- 


100     BUILDING  A  PROFITABLE  PRACTICE 

carditis,  or  cardiac  dilatation  mean  little  to  him,  but 
enlargement  of  the  heart,  an  ulcerated  condition  of 
the  valves  of  the  heart  or  disease  of  the  valves  of  the 
heart — explaining  the  pump  action  at  the  same  time 
— will  be  appreciated  by  most  people.  Always  take 
care  to  mention  the  scientific  term  at  the  same  time. 
Do  this  because  if  at  a  later  time  some  one  else  is 
called  to  see  the  case  his  Latin  designation  of  it  will 
not  take  them  by  surprise. 

After  this,  outline  the  hygiene  and  specify  the 
diet,  as  much  as  you  do  your  medicines — remember 
that  most  men  will  probably  prescribe  the  same 
medicine  in  most  diseases,  but  that  it  is  these  sup- 
posed minor  details  as  diet,  hygiene,  etc.,  that  make 
the  one  man  successful  and  the  other  a  failure  in  a 
given  case — and  then  give  your  prescriptions. 
Many  times  it  is  better  that  you  write  all  of  these 
directions  out  then  and  there.  After  you  have 
finished,  take  up  your  hat  and  stand  as  though  you 
were  expecting  something  else  to  happen.  The  peo- 
ple will  generally  ask  you  the  amount  of  your  fee. 
If  they  do  not  say  anything  about  the  fee,  and  if 
they  are  strangers,  say  on  leaving:  ''Well,  you  can 
pay  me  to-morrow  when  I  call. '  *  Then  they  will  be 
forced  to  bring  up  the  subject  the  next  day.  If  they 
do  not  they  are  probably  rogues.  Those  who  promise 
to  pay  Saturday  night  are  apt  to  be  dead  beats. 

WHEN    TO    REPEAT    CALLS. 

Beginners  are  apt  to  make  too  few  visits,  under 
the  impression  that  the  patients  or  their  relatives 


FIRST  VISIT  101 

might  ascribe  the  frequency  of  visits  to  self-interest. 
In  the  case  of  a  sutured  wound  it  is  good  practice 
to  see  the  case  on  the  third  day,  in  order  that  you 
may  be  sure  of  your  asepsis.  Then  again  on  the 
sixth  or  seventh  day,  when  the  sutures  may  be  re-^ 
moved.  Septic  wounds  that  are  active  should  be 
seen  at  least  every  other  day.  If  they  are  inflamed 
and  painful,  they  should  be  seen  every  day. 

Cases  of  grip,  etc.,  without  temperature,  should 
come  to  the  office  every  other  day  unless  you  spray 
their  noses  and  treat  them.  In  such  cases  daily 
visits  should  be  made ;  one  to  three  calls  is  the  aver- 
age generally  in  such  cases.  Coughs,  bronchitis 
with  no  temperature  should  come  every  alternate 
day.  In  acute  diseases  of  children,  see  the  patient 
daily  until  the  temperature  is  normal.  Except  in 
chronic  diseases,  such  as  tuberculosis,  etc.,  whenever 
a  patient  has  a  temperature  of  over  100°  F.  he 
should  be  in  bed  and  should  be  seen  daily.  If  he  has 
a  temperature  of  102i/^°  or  over  in  the  morning, 
see  him  again  in  the  evening  of  the  same  day.  If  the 
temperature  has  been  gradually  diminishing  for  a 
few  days  and  comes  down  to  normal,  omit  one  day 
in  making  a  call,  explaining  to  the  people  that  you 
do  so  to  save  them  the  added  expense.  See  tonsil- 
litis cases  daily  until  marked  improvement  takes 
place.  In  any  case,  if  the  patient  has  severe  pains 
that  are  not  relieved,  visit  him  again  the  same  day. 
In  inflammatory  conditions  of  any  kind,  when  pus  is 
slowly  forming,  every  alternate  day  is  sufficient.  In 
pneumonia,  appendicitis  or  any  very  serious  illness. 


102    BUILDING  A  PROFITABLE  PRACTICE 

call  three  or  four  times  a  day,  explaining  to  the  peo- 
ple, if  they  are  poor  or  penurious,  that  you  do  not 
intend  to  charge  for  all  of  these  visits,  but  that  you 
come  to  make  sure  that  everything  is  progressing 
safely.  In  every  case  leave  distinct  orders  that  you 
are  to  be  sent  for  in  the  event  of  the  patient  getting 
worse.  Most  people  would  rather  have  you  come 
yourself  without  being  sent  for.  If  there  is  any 
doubt  in  your  mind  as  to  the  advisability  of  your 
calling,  say  that  you  would  come  more  frequently, 
only  you  do  not  want  to  run  up  a  big  bill  on  them. 
If  this  does  not  bring  a  fitting  response  you  can  take 
it  for  granted  that  they  are  willing  to  take  the  re- 
sponsibility. In  doubtful  cases  let  them  bear  the 
responsibility  by  telling  them  to  send  unless  the 
patient  is  better.  Gynecic  cases  come  to  your  office 
once  or  twice  a  week,  as  the  case  may  be.  Likewise, 
catarrhal  conditions  of  nose  and  throat  should  be 
treated  two  or  three  times  a  week.  Eye  cases,  if 
severe,  should  be  seen  daily.  Gonorrhceal  cases 
should  come  twice  a  week  unless  you  irrigate  them, 
when  daily  visits  are  necessary.  Chancroids,  etc., 
daily. 

Patients  with  syphilis  in  its  early  stages  should 
come  every  three  or  four  days,  at  least.  Later 
on,  once  a  week.  Where  injections  are  given,  once  a 
week  at  least  for  six  months.  Pass  sounds  once  a 
week,  in  the  cases  that  need  them. 

Chronic  Cases. — Cancer  cases,  unless  they  are 
causing  marked  symptoms,  once  every  week  is  often 
enough  to  visit  them. 


FIRST  VISIT  103 

Pulmonary  Tuberculosis. — ^Among  the  poor  sel- 
dom is  it  necessary  to  go  more  than  once  a  week, 
unless  the  disease  is  very  active.  Stomach  cases 
should  report  to  you  once  a  week. 

x\lways  explain  to  patients  suffering  from 
chronic  disease  that  a  disease  which  has  been  a  long 
time  in  making  its  appearance  will  take  a  long  time 
in  disappearing,  and  that  many  changes  of  treat- 
ment are  necessary  before  recovery. 

DISCHARGING   A    PATIENT. 

Most  of  your  male  patients  will  importune  you 
to  let  them  go  out  as  soon  as  they  feel  better.  Be 
very  cautious  in  this  respect.  If  the  patient  has  had 
any  disease  that  may  possibly  cause  cardiac  degen- 
eration— as  rheumatism,  diphtheria,  pneumonia — 
keep  him  in  bed  for  at  least  a  week  after  the  fever 
and  symptoms  have  sudsided.  Surgical  cases,  with 
the  exception  of  fractures,  do  not  require  such  close 
confinement.  After  recovery,  do  not  be  in  a  hurry 
to  allow  a  patient  to  go  out  or  to  go  to  work.  It  is 
even  wiser  to  allow  him  to  do  without  consulting 
you;  at  any  rate,  err  on  the  side  of  caution.  How 
often  do  we  hear  the  story  that  Mr.  So-and-So  con- 
tracted pneumonia  or  what  not  because  the  doctor 
let  him  go  out  too  soon  after  his  illness,  and  fre- 
quently there  is  more  truth  than  poetry  in  the 
charge.  If  he  goes  out  on  his  own  accord,  or  with- 
out your  advice,  you  will  not  be  blamed  for  it. 

When  you  are  through  visiting  an  acute  case  and 
the  patient  is  well  on  to  recovery,  it  is  generally 


104    BUILDING  A  PROFITABLE  PRACTICE 

good  practice  to  tell  him  to  visit  you  at  your  office 
within  a  certain  number  of  days ;  this  will  sometimes 
prevent  your  patient  from  getting  a  relapse,  a  new 
disease  or  possibly  something  overlooked  by  your- 
self and  perhaps  found  by  your  neighbor  when 
called  in  on  emergency. 

MANAGEMENT    OF    THE    INCURABLES. 

Continue  visiting  your  incurable  patients.  They 
are  willing  to  pay  you  for  your  smile  and  encour- 
agement and  you  can  do  much  for  them  by  relieving 
them  of  many  of  their  minor  complaints.  Usually 
call  the  same  day  each  week  or  every  second  week, 
as  the  patient  may  be  able  to  afford.  Remember, 
your  visit  is  an  event  in  their  lives.  Do  not  repeat 
to  the  friends  every  time  you  come  the  fact  that  you 
cannot  possibly  cure  the  patient.  Be  always  cheer- 
ful and  hopeful  with  the  patient. 

MANAGEMENT  OF  THE  DYING  PATIENT. 

One  of  your  most  trying  experiences  will  be  the 
management  of  the  dying  patient  and  his  friends. 
You  may  safely  pronounce  that  the  end  is  near, 
when  in  an  adult  the  pulse  has  coirtinuously  mounted 
to  160  or  170  beats  per  minute,  together  with  the 
signs  of  pulmonary  oedema.  You  can  then  say  to  the 
friends  that  there  is  almost  no  hope,  but  that  while 
there  is  the  slightest  glimmer  of  life  we  must  do 
everything  that  we  can  for  the  patient's  comfort. 
Never  order  any  of  the  friends  out  of  the  room. 
Call  several  times  during  the  day  while  the  patient 


FIRST  VISIT  105 

is  dying,  each  time  suggesting  some  little  manoeuvre 
for  his  comfort.  Look  after  the  welfare  of  the 
friends,  by  giving  aromatic  .spirits  of  ammonia, 
valerian  or  bromides,  as  the  nervous  symptoms  may 
require.  Be  solicitous  for  the  welfare  of  each  of  the 
female  attendants,  but  do  not  be  insistent  in  order- 
ing them  to  bed  or  out  of  the  room,  etc.  Assure  the 
friends  that  the  patient  is  absolutely  unconscious 
and  that  he  does  not  suffer  the  slightest  pain.  Al- 
low as  many  of  them  in  the  room  as  may  wish  to 
come  in.  To  you  a  dead  person  may  not  mean  more 
than  a  piece  of  wood,  stone  or  any  other  inanimate 
thing,  but  to  the  relatives,  particularly  the  female 
portion,  the  body  is  still  a  dear  treasure,  and  any 
kindness  that  you  may  show  it  will  be  appreciated 
as  though  life  was  still  present.  For  this  reason 
autopsies  are  horrible  to  many  people.  While  they 
are  our  only  means  of  acquiring  much  advance  in 
diagnosis,  nevertheless  you  must  not  seek  to  do  them 
in  your  early  private  practice.  This  applies  with 
especial  force  among  the  Hebrew  and  Irish  races. 
Do  not  remain  in  the  room  when  the  final  issue  is 
imminent.  When  the  patient  has  passed  away,  and 
after  the  first  pangs  of  grief  have  subsided,  close 
the  eyelids  and  take  a  handkerchief  or  cloth  and  tie 
up  the  fallen  jaw. 

Do  not  suggest  the  name  of  an  undertaker,  as 
this  will  almost  certainly  do  you  harm.  There  are 
many  who  half  in  joke  and  half  in  earnest  will  con- 
nect your  names. 

Many  physicians  call  in  and  view  the  body  when 


106    BUILDING  A  PROFITABLE  PRACTICE 

it  is  laid  out  in  the  casket,  ostensibly  to  console  the 
friends  and  to  show  their  interest  in  the  one  who 
has  departed.  It  often  serves  to  disarm  unjust 
criticism. 

WHEN  A  PATIENT  IS  ALBEADY  DEAD. 

When  called  in  on  such  a  case  use  the  same  tactful 
means  as  above,  closing  the  eyes  tight.  Inquire  into 
the  details  of  death,  etc.  If  you  have  not  treated 
the  patient  recently,  unless  he  be  a  chronic  under 
your  care,  explain  to  the  people  that  the  law  com- 
pels you  to  notify  the  coroner's  office  at  once.  In 
some  States  the  district  attorney's  office  takes  up 
the  duties  of  the  coroner.  Tell  them  that  there  will 
be  no  autopsy  or  other  trouble  in  the  case.  Leave 
a  note  for  the  coroner,  explaining  the  situation. 

Sometimes  you  will  be  able  to  collect  for  such 
visits,  and  it  is  better  to  do  so  at  once;  unless  you 
are  the  family  physician,  you  will  not  be  likely  to 
get  your  fee  at  a  later  date. 

SENDING  PATIENTS  TO   HOSPITALS. 

Do  not  be  in  a  hurry  to  send  patients  to  the  hos- 
pital. This  is  a  failing  with  many  young  doctors, 
who  in  their  rugged  honesty  are  anxious  to  save 
the  patient  expense  or  get  away  from  the  responsi- 
bility of  difficult  or  chronic  cases.  These  are  the 
very  cases  that  you  should  strive  to  study,  and  they 
are  the  ones  that  will  bring  you  your  reputation. 
Don't  suggest  hospital  unless  some  grave  operation 
is  indicated  which  the  patient  cannot  afford  to  have 


FIRST  VISIT  107 

done  at  home.  The  laity  do  not  view  hospitals  in 
the  favorable  light  that  you  do.  To  them  the  sym- 
pathy of  friends,  the  hundred  and  one  comforts  of 
home,  more  than  counterbalance  the  sight  of  trained 
nurses  and  frequent  examinations.  Few  people  are 
anxious  to  go  to  hospitals,  and  it  is  your  business 
to  treat  them  at  home.  If  you  cannot  do  so,  then 
you  are  a  failure  in  so  far  as  that  particular  case 
is  concerned. 

No  patient  is  too  poor  to  treat.  Do  not  send  the 
poor  patient  or  any  other  to  a  dispensary  in  order 
that  they  may  save  the  expense.  Get  the  experience 
yourself.  No  patient  who  goes  to  hospital  or  dis- 
pensary ever  afterward  has  the  same  regard  or  re- 
spect for  you  as  before,  because  there  the  personal 
worship  or  idolatry  is  lost  since  they  realize  that 
there  are  other  men  who  are  just  as  clever  as  you 
are,  or  mayhap  other  patients  that  they  meet  there 
will  convince  them  of  the  superiority  of  some  one 
else.  Whatever  the  reason  may  be,  the  patient  sel- 
dom has  quite  the  same  confidence  in  you.  Once  a 
patient  gets  free  treatment,  he  is  like  the  rest 
of  us  who,  when  we  once  get  free  tickets  for  a  the- 
atre, or  railroad  journey,  never  afterward  feel  like 
paying  for  similar  services. 

If  you  can  do  absolutely  nothing  for  the  patient, 
send  him  to  one  of  your  young  friends,  who  are 
struggling  to  get  experience  in  that  particular 
specialty.  He  will  be  glad  to  treat  him  for  the  ex- 
perience or  for  a  very  small  fee.  The  patient  will 
appreciate  it  as  a  favor. 


108    BUILDING  A  PROFITABLE  PRACTICE 

In  all  acute  diseases  of  a  minor  character  the 
tendency  is  always  toward  recovery,  and  you  can 
do  as  much  as  any  specialist.  The  tendency  of 
sending  every  case  to  the  specialist  is  the  cause  of 
the  present  cry  of  many  general  practitioners  that 
they  cannot  make  a  good  living.  If  you  can  honestly 
do  so,  treat  the  case.  Do  not  say,  ''I  do  not  under- 
stand this  specialty,"  but  treat  the  patient  and  have 
him  come  back.  In  the  meantime  read  it  up  as  you 
should  do  with  all  of  your  cases.  You  will  find  that 
nine  times  out  of  ten  you  can  do  as  well  as  the  spe- 
cialist. It  is  only  in  very  difficult  cases,  and  these 
are  generally  of  a  chronic  nature,  that  you  must 
yield  the  patient  to  him. 


CHAPTER  XII. 

Get  the  names  and  addresses  of  all  the  ordinary 
practical  nurses  that  you  meet  in  the  course  of  your 
practice ;  write  their  names  in  the  rear  part  of  your 
visiting  list ;  make  a  note  of  the  nationality,  age  and 
general  characteristics.  Do  this,  because  it  will  be 
of  much  value  to  you  in  selecting  a  suitable  nurse. 
The  selection  of  a  suitable  nurse  oftentimes  requires 
as  much  discretion  as  the  selection  of  a  suitable 
medicine;  to  send  an  irritable,  although,  possibly, 
clever,  nurse  to  a  nervous  patient  may  invite  dis- 
aster. Likewise,  to  place  one  that  requires  much 
service  and  attention  in  a  poor  family  will  cause 
much  adverse  comment,  and  an  attractive  girl  may 
cause  much  jealousy  in  some  families.  Therefore, 
make  a  note  of  the  qualifications. 

Don't  joke  with  nurses — be  professional  in  every 
way;  the  laity,  particularly  the  feminine  portion, 
are  very  suspicious  of  such  levity,  and  are  apt  to 
judge  you  both  wrongly. 

When  an  illness  is  very  severe,  and  will  last 
more  than  a  week,  suggest  the  hiring  of  a  nurse. 
People  do  not  hesitate  to  spend  the  money  for  such 
purposes  nearly  as  much  as  you  think  they  do.  The 
nurse  will  do  much  to  make  your  own  position  easier. 
The  chief  requisite  of  a  nurse  should  be  that  she 
can  hold  her  own  tongue ;  any  intelligent  female  can 

109 


110    BUILDING  A  PROFITABLE  PRACTICE 

be  instructed  as  to  her  duty.  I  am  speaking  now  of 
nurses  who  will  prepare  the  meals  in  addition  to  the 
nursing. 

Trained  nurses  are  a  luxury  that  few  of  your 
early  patients  can  afford.  Don't  try  to  force  people 
to  employ  them  unless  they  can  afford  it.  Here, 
again,  silence  on  the  part  of  the  nurse  is  golden. 
Many  of  them  have  a  habit  of  boasting  how  great 
their  friend,  Dr.  So-and-So,  is,  or  what  he  does  in 
such  cases.    Avoid  the  ministrations  of  such  angels. 

Insist  on  a  nurse,  or  some  kind  of  attendant, 
during  the  night  for  all  of  your  cases  of  delirium 
tremens. 

In  sending  for  ordinary  nurses,  give  the  family 
a  list  of  names  and  addresses,  and  let  them  make  the 
bargain  as  to  wages,  etc. 


CHAPTER  XIII. 

Medical  Finance. 

You  have  doubtless  entered  the  medical  profe^ 
sion  out  of  mixed  motives ;  in  fact,  most  of  the  things 
we  do  in  life  we  do  out  of  mixed  motives.  In  the 
first  place,  you  believe  it  to  be  a  noble  and  honor- 
able calling,  one  that  appeals  to  you;  that  you  can 
do  so  much  good  in  the  world  by  the  relief  of  pain 
and  cure  of  diseases;  that  you  may  discover  new 
things  and  become  famous;  that  you  will  be  re- 
spected and  honored  among  men;  that  people  will 
look  up  to  you  for  counsel  and  advice.  But  beyond 
this,  there  are  few  among  you  who  do  not  expect 
to  make  a  living  out  of  your  calling,  a  living  com- 
mensurate \fith  your  state  in  life,  and  a  surplus  that 
will  support  you  in  your  old  age,  and  some  heritage. 

The  ideal  physician,  as  he  existed  in  the  minds 
of  the  laity  of  the  past  centuries,  was  one  who 
labored  incessantly,  paid  his  bills  now  and  then,  and, 
dying,  left  his  family  in  distressed  circumstances; 
seldom  did  he  leave  enough  to  keep  them  from  ard- 
uous labor.  We  have  all  seen  physicians  of  national 
reputation  who  had  big  practice,  kept  up  great  style, 
etc.,  and  yet  their  estates  were  valued  at  a  mere  pit- 
tance. This  might  be  all  right  in  the  good  old  days, 
but  to-day  sentiment  is  not  in  the  ascendant.  The 
man  who  fails  to  accumulate  sufficient  to  keep  the 
wolf  from  the  door  of  his  family  has  failed — sig- 
nally failed — in  his  duty  as  well  as  in  his  profession. 

Ill 


112    BUILDING  A  PROFITABLE  PRACTICE 

FEE. 

Legally  the  amount  of  the  fee  is  a  matter  gov- 
erned by  custom  or  practice.  The  custom  of  the 
particular  locality  governs  this  matter.  If  the  cus- 
tomary price  for  a  visit  is  $2,  then  a  physician,  who 
in  response  to  a  request  for  his  services  makes  a 
visit  with  no  understanding  as  to  the  amount  of  fee 
to  be  paid,  becomes  entitled  to  $2. 

It  is  a  very  difficult  matter  to  lay  down  a  fee  table 
that  will  cover  a  large  territory.  For  ordinary  prac- 
titioners, without  any  special  training  or  preten- 
sions as  to  superior  skill,  the  average  fee  is  $2  for 
a  house  visit.  In  some  parts  of  large  cities  this  may 
go  a  dollar  higher.  It  will  be  several  years  before 
you  can  expect  a  higher  fee  for  an  ordinary  visit, 
that  does  not  require  some  special  knowledge,  nor 
consume  more  than  one-half  hour  of  your  time.  In 
either  case,  you  can  sometimes  collect  more.  For 
the  busy  man,  oftentimes  a  fee  of  two  dollars  is  far 
more  remunerative  than  a  fee  of  five  dollars,  be- 
cause he  must  spend  a  long  time  with  the  patient 
who  pays  five  dollars  per  visit,  while  he  might  make 
three  or  four  visits  on  the  less  remunerative  clien- 
tele. If  a  man  has  superior  attainments  in  general 
practice  or  be  a  specialist,  he  may  ask  a  higher  fee. 
This  is  certainly  true  in  a  large  city  like  New  York. 
In  the  better-class  neighborhoods,  where  the  services 
of  skilled  men  are  required,  from  $3  to  $10  is  the 
standard  fee.  In  most  of  the  large  cities  of  the 
second  class  throughout  the  East  a  fee  of  two  dollars 


MEDICAL  FINANCE  113 

per  house-visit  for  a  general  practitioner  is  a  stand- 
ard at  the  present  time.  The  courts  generally  rec- 
ognize such  a  fee  as  not  excessive.  In  Philadelphia, 
for  the  most  part,  a  fee  of  $1  per  visit  is  the  preva- 
lent charge ;  this  is  true  of  Pennsylvania  towns  and 
throughout  the  South.  If  one  has  a  well-to-do  clien- 
tele, it  is  quite  possible  to  charge  by  the  case  instead 
of  the  number  of  visits.  This  is  the  ideal  method,  but 
is  applicable  only  to  a  few ;  the  vast  number  of  sick 
are  not  able  to  afford  it,  and  custom  has  made  the 
rule  of  charge  by  visit,  so  that  the  courts  usually 
judge  one's  services,  as  far  as  general  practice  is 
concerned,  by  allowing  a  stated  price  per  visit.  'In 
small  towns  and  country  places  this  fee  is  reduced 
to  from  $1  to  $1.50.  If  the  visit  entail  a  mile  or 
more  of  travel,  the  country  doctors  charge  so  much  a 
mile.  In  the  city,  mileage  is  seldom  charged  for. 
The  very  lowest  charge  for  a  visit  in  any  part  of  the 
country  should  be  $1.  In  view  of  the  increasing 
cost  of  living,  $3  should  be  the  proper  average. 
Some  physicians  charge  $1  extra  for  the  first  call, 
and  the  regular  price  for  each  call  thereafter. 

NIGHT  CALL  FEE. 

If  the  night  call  be  an  emergency  one,  in  which 
the  people  have  sent  for  their  regular  attendant, 
charge  double  the  regular  day  fee,  or  at  least  $3. 
If  there  is  no  such  complication,  and  if  you  think 
that  you  can  retain  the  family,  you  may  consider 
whether  it  be  better  to  do  this  or  not.    In  most  cases 

8 


114    BUILDING  A  PROFITABLE  PRACTICE 

for  a  beginner  it  is  unwise  to  do  so.  Charge  double 
the  fee  at  night  to  strangers  in  town,  transients  and 
to  roisterers. 

OFFICE  FEE. 

In  the  office,  for  ordinary  consultation,  without 
any  special  time-consuming  treatment,  the  average 
fee  is  $1.  Men  who  have  experience  charge  $2,  spe- 
cialists from  $5  to  $10.  The  average  specialist's 
consultation  fee  is  $10  at  the  office;  for  an  outside 
call  it  varies  from  $10  to  $25.  Very  few  men  exceed 
these  prices  in  their  own  cities.  Many  of  the  best 
specialists  in  New  York  gladly  see  patients  referred 
to  them  by  other  doctors  for  $2  or  $3  when  accom- 
panied by  a  note  from  the  doctor,  stating  their  in- 
ability to  pay  more.  This  applies  more  particu- 
larly to  throat  and  eye  surgeons.  While  it  is  quite 
true  that  they  are  sometimes  imposed  on,  yet  if 
there  be  a  sufficient  number  of  cases,  it  is  quite  re- 
munerative. Office  fees  for  the  majority  of  general 
practitioners  in  New  York  average  from  $1  to  $2. 
For  those  who  have  a  well-to-do  practice,  or  who 
have  more  reputation,  $3  to  $10  is  secured.  In 
some  of  the  country  towns  and  small  cities  50  cents 
is  received  for  office  work.  This  is  too  small  for 
good  work,  but  you  must  not  try  at  once  to  break 
the  fee  table  that  patients  have  been  accustomed 
to  pay  for  a  generation.  In  country  places,  $10  and 
$15  is  the  rule  for  confinement  cases ;  in  the  city,  $20 
and  $25.  Charge  $1  for  vaccinations,  unless  others 
in  the  town  do  it  for  less.  In  such  a  case  let  the 
patient  get  the  virus,  and  do  it  for  nothing. 


MEDICAL  FINANCE  US 

Any  special  work,  such  as  opening  abscesses, 
injecting  morphine,  passing  sounds,  electrical  treat- 
ment, etc.,  is  worth  a  double  office  fee,  and  most 
people  will  gladly  pay  it.  In  some  places  one  and  a 
half  times  the  office  fee  is  charged  for  such  work. 
Don't  be  afraid  to  ask  the  regular  price  of  the  visit 
or  call.  Either  your  services  are  worth  it  or  they 
are  worth  nothing.  Which  shall  it  be!  People 
would  not  employ  you  if  they  thought  that  your  ad- 
vice was  of  no  value.    So  don 't  flinch. 

For  surgical  dressings  in  most  cities  the  charge 
is  from  $1.50  to  $2.  In  places  where  the  office  fees 
are  less  they  are  to  be  scaled  in  proportion.  You 
can  explain  that  it  is  unfair  to  ask  you  to  spend  25 
cents  on  a  dressing  without  pay  for  the  same.  In 
sewing  wounds  it  is  the  custom  of  some  to  charge  $1 
per  stitch,  and  nothing  for  their  removal.  I  believe 
it  to  be  better  to  charge  $2  the  first  visit  and  a  dress- 
ing fee  of  $1,  or  more,  at  each  subsequent  visit;  it 
does  not  look  so  big  to  the  patient. 

Whether  you  can  charge  for  an  examination  of 
urine,  sputa  and  blood  is  often  a  delicate  matter. 
Generally,  it  is  unwise  to  try  to  collect  for  urine 
examination,  but  for  the  others  it  is  customary  to 
charge,  and  you  should  do  it  yourself  and  collect  a 
fee.  If  a  Health  Department  does  it,  of  course  you 
must  not  charge  anything.  Where  repeated  urine 
examinations  are  necessary,  and  you  do  not  see  the 
patient,  charge  one-half  an  office  fee  for  the  exam- 
ination. 


116    BUILDING  A  PROFITABLE  PRACTICE 

A  patient  who  sincerely  tries  to  advertise  you, 
who  goes  out  of  his  way  to  bring  you  patients,  is 
certainly  worthy  of  consideration,  and  should  re- 
ceive either  extra  attention  from  you  (and  let  him 
know  that  he  is  getting  it),  or  else  you  may  lessen 
his  bill,  also  letting  him  know  that  it  is  a  mark  of 
your  gratitude. 

There  are  special  fees  for  the  other  preventive 
inoculations,  such  as  typhoid,  acne,  etc.,  but  $2  is 
the  average.  If  the  patient  must  have  a  revaccin- 
ation  for  small-pox  it  is  seldom  wise  to  charge  for 
it;  on  the  other  hand,  if  the  patient  returns  because 
of  redness,  oedema,  etc.,  charge  for  such  visits. 
Explain  to  the  patient  beforehand  that  such  things 
will  certainly  occur.  Don't  charge  for  the  certifi- 
cate, or,  in  fact,  for  most  forms  of  certificates,  ex- 
cept as  mentioned  later. 

FEES  IN  OBSTETRIC   CASES. 

In  obstetric  cases  there  are  several  methods  of 
charging  and  collecting;  the  method  most  in  vogue 
is  to  charge  a  lump  sum,  covering  examination  of 
patient,  urine,  delivering,  and  eight  or  nine  later 
visits.  Another  method  that  is  preferable  is  to 
charge  the  patient  for  the  preliminary  examination 
and  for  each  subsequent  oflBce  call,  with  no  charge 
for  the  urine  examination,  and  then  a  lump  sum  for 
the  delivery  and  P.  P.  calls ;  every  call  or  visit  before 
labor  begins  being  charged  for  in  addition.  In  this 
way  the  amount  does  not  seem  so  large,  and  a  more 
nearly  proper  fee  is  secured.  Another  method,  seldom 


MEDICAL  FINANCE  117 

employed,  is  to  charge  so  much  for  the  confinement, 
subsequent  visits  to  be  paid  for  as  house-visits.  In 
the  British  Isles  this  system  of  collection  is  much 
in  vogue.  In  such  cases  $10  is  the  usual  fee  for  the 
delivery  alone.  When  a  lump  sum  is  charged  the 
fee  covers  eight  or  nine  visits.  If  there  is  any  ill- 
ness of  the  infant  after  the  ninth  day,  treatment 
should  be  charged  for.  Likewise,  if  the  mother  is  ill 
more  than  ten  or  twelve  days  after  labor,  you  should 
demand  extra  compensation.  If  you  explain  when 
taking  the  case  that  your  fee  covers  the  urine  ex- 
amination, the  delivery  and  eight  or  nine  calls  there- 
after, there  will  be  no  room  for  complaint.  As  a 
matter  of  fact,  there  is  seldom  any  fault  found, 
where  the  patient  is  ill  for  more  than  twelve  days, 
if  an  extra  charge  for  each  visit  is  made. 

COLLECTION  OF  MIDWIFERY  FEES. 

As  to  the  collection  of  the  midwifery  fees,  in 
some  places  it  is  customary  to  receive  a  deposit  of 
$5  to  $10  at  the  time  of  engagement  of  your  services. 
This  a  good  plan  in  tenement  quarters,  as  it  pre- 
vents the  people  from  changing  their  minds  and 
going  to  another  doctor;  also,  if  you  are  not 
promptly  on  hand  when  they  send  for  you,  they  will 
not  be  in  such  a  hurry  to  call  the  doctor  next  door. 
When  this  deposit  is  paid  beforehand,  the  balance 
is  paid  at  the  end  of  the  ninth  day,  or  one-half  of  the 
balance  on  delivery,  and  the  rest  at  the  termination 
of  the  case.  Among  the  poor  this  is  a  convenient 
way  of  paying  the  bill.    Another  good  method  is  to 


118    BUILDING  A  PROFITABLE  PRACTICE 

charge  C.  0.  D. — collect  on  the  delivery  of  the  child. 
If  such  an  understanding  is  made,  and  it  can  easily 
be  brought  up,  saying  at  the  engagement  that  it  is 
the  custom  to  pay  when  the  child  is  delivered,  there 
will  be  no  valid  excuse  if,  when  they  fail  to  pay  you 
the  night  of  the  delivery,  you  ask  whether  there  has 
not  been  some  financial  arrangement  made  as  to 
payment.  This  is  the  best  time  to  bring  this  matter 
up,  as  then  mother  and  father  are  grateful  to  you, 
more  so  than  they  ever  will  be  in  their  lives  there- 
after; there  is  money  in  the  home,  in  most  cases,  and 
there  will  not  be  any  hard  feeling  engendered,  as 
they  appreciate  your  hard  work,  etc.;  whereas,  if 
you  wait  until  the  termination  of  the  case — the  child 
may  die  meanwhile — all  of  the  money  goes  to  the 
undertaker;  the  mother  may  get  up  some  complica- 
tion, etc.,  and  some  one  may  blame  you  for  this  and 
that,  and  many  other  things  may  conspire  to  keep 
you  out  of  your  hard  earned  money  forever.  If  you 
do  not  get  paid  at  this  time,  then  the  day  before  your 
last  visit  inform  the  patient  that  to-morrow  will  be 
your  last  visit,  and  this  is  hint  enough  to  most  peo- 
ple. There  is  no  excuse  for  people  failing  to  have 
your  money  ready  on  the  delivery  of  the  child.  They 
have  nine  long  months  to  prepare  for  it.  It  is  not 
like  an  illness  that  comes  up  suddenly,  and  if  they 
cannot  pay  for  it  then  and  there,  there  is  not  much 
likelihood  of  their  ever  being  able  to  pay  for  it. 
These  remarks,  of  course,  do  not  apply  to  people 
in  easy  circumstances,  or  to  those  owning  property. 


MEDICAL  FINANCE  119 

FEES  IN  OPERATIVE   CASES. 

The  rates  for  operations  vary  with  the  locali- 
ties, but  the  variations  are  greater  than  for  medical 
work.  There  are  few  hard  and  fast  rules  to  guide 
you.  In  the  absence  of  any  fee  table,  the  rates  al- 
lowed by  accident  insurance  companies  will  gener- 
ally be  accepted,  and  they  are  as  follows : 

SCHEDULE  OF  OPERATIONS. 

Section  1. 

Opening  the  Abdominal  Cavity  (Laparotomy)  for — 

Appendicitis   or  any  operation   on   any  organ    (tapping 

excluded)     $100.00 

Fixation  or  Removal  of  Kjdney 100.00 

Tapping  of  Abdomen  or  Bladder 25.00 

Rectal  Operations: 

Excision   or    ligation   of    Hemorrhoid's    (internal    or   ex- 
ternal)       25.00 

Operation  for   Prolapsed  Rectum    25.00 

Operation  for  Fistula  in  Ano    25.00 

Excision  of  Rectal  Polypus  25.00 

Excision  of  or  Colostomy  for  Malignant  Rectal  Growth.  100.00 

Any  Cutting  Operation  on  Bladder  (excluding  tapping) . .  100.00 

Ligation  of  Artery  for  Aneurism 50.00 

Ligation  or  Excision  of  Varicose  Veins 25.00 

Acupressure,  Ligation,  or  Excision  fob  Varicocele 25.00 

Bronchotomy,  Tiiyrotomy,  Laryngotomy,  Laryngo-trache- 

otomy,  or  Tracheotomy   50.00 

Esophagotomy    100.00 

Incision  of — 

Abscess,  Boil,  Felon,  or  Carbuncle 5.00 

Minor  Operation  on — 

Eye,  Ear,  Nose,  or  Throat 10.00 

Removal  of  Ingrowing  Toe  Nail 10.00 

Incision  and  Curetting  Cystic  Tumor  of  Tendon  Sheath.  15.00 


120    BUILDING  A  PROFITABLE  PRACTICE 

Incision  or  Excision  of  Hydrocele  Sac,  or  Tapping  Same.  .  $25.00 
Extirpation  of — 

Benign  Tumor  15.00 

Malignant  Tumor    50.00 

Sequestrotomy   (removal  of  dead  bone) 35.00 

Skull  Trephining    100.00 

Curetting  for  Bone  Ulcer  15.00 

Operation  fob  Mastoiditis  50.00 

Incision  fob — 

Synovitis    (inflammation  of  the  lining  membrane  of  a 

joint)     25.00 

Injection  of — 

Antitetanic  serum  into  frontal  lobe  of  brain 100.00 

Section  2. 

Amputation  of — 

Foot,  Hand,  or  Forearm   25.00 

Leg,  at  or  below  knee 60.00 

Arm  above  elbow 50.00 

Thigh    100.00 

Fingers,  one  or  more  entire 10.00 

Toes,  one  or  more  entire  25.00 

Reduction  of  Dislocation  of — 

Shoulder,  Elbow,  Hip,  Knee,  or  Ankle 25.00 

Wrist  or  Jaw  15.00 

Fingers,  one  or  more 10.00 

Excision  of — 

Shoulder-,  Hip-,  or  Knee-Joint    100.00 

Elbow-,  Wrist-,  or  Ankle-joint  50.00 

Reduction  of  Fracture  of — 

Nose,  Lower  Jaw,  Collar-bone,  or  Shoulder-blade 25.00 

Breast  Bone    10.00 

Rib  or   Ribs    10.00 

Upper  Arm    35.00 

Forearm,  one  or  both  bones 25.00 

Wrist  or  Hand   15.00 

Fingers,  one  or  more 10.00 

Pelvis  or  Sacrum,  any  of  the  bones  of 50.00 


MEDICAL  FINANCE  121 

Coccyx     $10.00 

Thigh     75.00 

Knee  Cap  50.00 

Leg  Bones,  one  or  both  50.00 

Foot,  two  or  more  bones,  not  toes 15.00 

Toes,  one  or  more   10.00 

Removal  of  Shot  or  Buuc^t  25.00 

Ant  Cutting  Operation  for — 

The    radical    cure    of    the    Reducible,    Irreducible,    or 

Strangulated  forms  of  abdominal  Hernia  100.00 

Suturing  Wounds    5.00 

The  following  fee  table  was  compiled  by  two 
prominent  New  York  physicians  and  surgeons  in 
active  hospital  and  private  practice,  and  published 
in  the  New  York  Herald,  October  24,  1909.  It  is 
made  to  apply  to  four  classes  of  practice  in  the  city 
of  New  York.  From  my  own  investigations,  the 
average  fees  obtained  from  the  first  three  classes 
are,  perhaps,  25  per  cent,  less  than  those  stated  in 
the  list.  In  the  instance  of  the  laboring  class,  it  is 
in  many  instances  50  per  cent.  less.  However,  in 
the  main,  the  table  fairly  well  represents  prices 
obtained  among  the  well-to-do : 

TABLE. 

New  York  Fees. 


s 

s 

Case.  ^ 


^ 


h^  u  n  > 

Abscess,  ordinary $2  $3  $5  $10 

Abscess,  important 10  25  60  100 

Amputations,  easy 20  40  60  100 

Anaesthesia,     general,     chloroform, 

ether  or  the  like 6  5  10  50 


122    BUILDING  A  PROFITABLE  PRACTICE 

New  York  Fees. 

I         s    i 

o       s       ^       i 


Case.  3*8 


•^  o         m         > 

Anaesthesia,  by  means  of  local  freezing 

applications $3  $5      $10      $25 

Anaesthesia  by  cocaine,  stovaine  or 

the  like 3  5        10        25 

Anthrax 10  15        25        50 

Apparatus,  compressing  methodically    5  10        15        25 

Apparatus,  supporting  plaster,  sili- 
cate, starch 10  15        25        50 

Asphyxia  from  submersion  or  intoxi- 
cants      5  10        15        25 

Bandages 3  5        10        25 

Blood  letting 5  10        25        50 

Burning,  thermocautery  or  by  elec- 
tricity (at  house) 6  10        20        40 

Catherization  of  the  oesophagus 10  15        25        50 

Catherization  of  the  Eustachian  tube  3  5         10        20 

Cauteries,  moxas,  seton  and  the  like.  3  5         10        20 

Cauterization  on  the  spot 3  5        10        20 

Certificates  on    ordinary   paper    at 

office 12  3  5 

Certificates    on    ordinary    officially 

stamped  paper 1  2  3          6 

Certificates    on    descriptive    official 

paper 1  2  3          6 

Certificates  of  insanity,  of  keeping 

indoors  and  of  seclusion 3  5        10        25 

Certificates    of    life    insurance    or 

annuity 2  3  5        10 

Consultation  with  two  colleagues  of 

equal  rank 3  5        10      100 

Consultation  with  specialist 10  15        25      100 

Dressings,  small 2  3  5        10 

Dressings,  large 3  5        10        25 

Dressings,  simple 2  3  5        10 

Dressings  of  extensive  bums,  gan- 
grenes, large  cancers,  wounds 5  10        15        25 

Electrification,  ordinary 2  3  5        10 


o 

« 

> 

$25 

$100 

$200 

50 

200 

500 

50 

150 

300 

MEDICAL  FINANCE  128 

New  York  Fees. 


o 
Case.  ^ 

o 

•g 

Empyema,  ordinary  operation $15 

Empyema,  with  resection  of  a  rib .  .  .  25 

Empyema,  by  Estlander  process 25 

Extracting  a  partly  detached  nail, 
useless  particles 2  5        10        25 

Extirpation  of  cysts,  superficial  fi- 
brous tumors,  haematomata,  or  in- 
flamed serous  sacs 10        25        50      100 

Extraction  of  foreign  bodies;  easy, 
from  superficial  tissues 3  5        10        25 

Extraction  of  foreign  bodies,  laborious 
from  deep  tissues  and  lungs 20        35       100      250 

Fractures  with  temporary  retaining 
apparatus 5        10        50      100 

Fractures,  ribs,  shoulder-blade,  breast- 
bone, skull  and  the  like 10        20        50      100 

Fractures,  small  bones 10        25       100      250 

Fractures,  collar-bone,  radius  or  cubi- 
tus, fibula,  simple 25        50      100      200 

Fractures,  humerus,  forearm,  knee, 
fibula,  elbow 30 

Fractures,  leg,  shoulder,  knee  cap ...   50 

Fractures,  thigh,  neck  or  diaphysis, 
with  apparatus 75 

Fractures,  leg,  bi-malleolal 25 

Fractures,  hip  bone,  pelvis,  vertebral 
column 75 

Fractures,  skull  spHntered 30 

Fractures,  dangerous  or  comminuted. 


more 50 


Foreign  bodies  in  stomach 50 

Foreign  bodies  in  nose 3 

Foreign  bodies  in  ear 3 

Foreign  bodies  in  eye,  simple 3 

Foreign  bodies  in  eye,  complicated . .  5 
Haematoma,     emptying,     drainage, 

tube,  packing 10        20        50      100 


50 

100 

200 

75 

150 

300 

150 

250 

400 

100 

150 

200 

150 

250 

500 

50 

100 

300 

75 

150 

400 

100 

200 

500 

5 

10 

25 

5 

10 

25 

5 

10 

25 

10 

25 

50 

« 

S 

i 

•s 
n 

'3 
> 

$5 

$10 

$25 

25 

125 

250 

10 

50 

100 

3 

5 

100 

3 

5 

10 

5 

25 

100 

3 

15 

25 

3 

15 

100 

3 

15 

100 

3 

5 

10 

124    BUILDING  A  PROFITABLE  PRACTICE 

New  York  Fees. 


o 
Caub.  ? 

•c 

i 

Haemostasia,  simple,  by  dressing. ...  $3 

Haemostasia,  by  ligature 5 

Hydrocele,  emptying  and  modifying 

injection 5 

Injections,  hypodermic 2 

Injections  into  the  muscles 2 

Injections  of  antitoxin  serum 3 

Injections  in  same  place,  preventive 

or  succeeding  ones 2 

Injections  of  serum 2 

Injections  of  serum,  following 2 

Leeches 2 

Ligatures,    arterior-radical,    cubital, 

humeral,  facial,  temporal 10        15        50      150 

Ligatiu-es,  tibial,  peroneal,  popliteal, 

femoral 20        30        50      100 

Ligatures,  lingual,  carotidal,  of  hands 

or  feet 25 

Ligatures,  axillary,  subclavian 75 

Luxations,  of  fingers  or  toes 5 

Luxations  of  the  thumb,  of  the  lower 

jaw 5 

Luxations,  of  the  wrist;  tibio-tarsal. .  10 

Luxations,  elbow,  shoulder,  hip  bone.  25 
Luxations,  complicated,  use  of  force 

or  apparatus  (twice  the  above) ...  50 

Massages,  ordinary 3 

Massages,  ordinary,  succeeding  ones.  2 

Massages,  special 2 

Nail,  ingrowing,  dressing 2 

Ntul,  ingrowing,  radical  cure 25 

Night  passed   without   agreeing   on 

price  (see  Time  passed). 
Nurses,  selection  or  examination  at 

the  doctor's  house  or  office 2          3        15        25 


50 

100 

250 

100 

200 

500 

10 

50 

150 

10 

50 

100 

20 

50 

100 

50 

100 

200 

100 

200 

400 

5 

10 

25 

3 

5 

10 

3 

5 

10 

3 

5 

10 

40 

100 

200 

MEDICAL  FINANCE  125 

New  York  Fees. 


Case.  a 

o 

Nurses,  outside  of  house,  at  public 
offices  or  at  the  patient's  place ....  $3 

Paronychia 2 

Paracentesis 10 

Paracentesis,  succeeding  ones 5 

Perforation  of  the  chest,  simple 20 

Perforation  of  the  chest,  simple,  suc- 
ceeding ones 10 

Phlegmon,  diffused,  deep,  large  open- 
mg 10 

Plugging,  complete,  of  the  nasal 
cavities 3 

PoljTpi,  nasal  and  uterine 20 

Punctures  of  different  cavities  and 
modifjdng  injections 15 

Scraping  of  a  bone  or  ganglion 50 

Skin  grafting 10 

Sphnters  and  sequestrations;  easy.  . .     3 

Splinters,  laborious  removal 5        10        50      100 

Sprains,  strains  (see  Bandages,  Mas- 
sages). 

Time  by  the  hour  at  night  or  hour  of 
time  in  going 5 

Tooth  pulhng 2 

Tracheotomy,  simple,  child 25 

Tracheotomy,  compUcated,  or  adult.  30 

Traction  movement,  each  quarter 
hour 3 

Trepanning,  simple 25 

Tube  inserting  in  larynx 10 

Tube  inserting  in  larynx,  following 
ones 5 

Tumors,  adenoid,  of  nasopharynx, 
abrasion 25 

Tumors  under  tongue  (Ranula),  sim- 
ple incision 5 

Tumor  imder  tongue,  removal 25 


$5 

$15 

$25 

3 

15 

25 

15 

50 

100 

10 

25 

50 

30 

50 

100 

15 

50 

100 

20 

50 

100 

5 

10 

25 

30 

50 

100 

25 

50 

100 

75 

150 

500 

20 

50 

100 

5 

10 

25 

10 

20 

100 

3 

5 

10 

40 

100 

250 

50 

100 

500 

5 

20 

25 

50 

200 

500 

20 

100 

500 

10 

25 

50 

50 

100 

500 

10 

50 

100 

50 

100 

200 

126    BUILDING  A  PROFITABLE  PRACTICE 


New  York  Fees. 


Case. 


Visit  of  immediate  urgency  at  an 

hour  fixed  for  a  colleague. 
Visit  from  seven  to  ten  P.  M.,  asked 

for  and  demanded  after  seven 

o'clock 
Visit  in  the  morning,  summer,  six  to 

seven  o'clock   (April  to  end  of 

September). 

Cupping,  simple 2 

Cupping,  with  the  scarificator 2 

Vaccination 2 

Vaccination,   each  other  person   of 

family 2 

Visit,  from  seven  A.  M .  to  seven  P.M.     2 
Visit  Sundays,  seven  A.  M.  to  ten 

P.M 

Visit  from  ten  P.  M.  to  seven  A.  M. 
Visit,  many  at  the  same  place,  each 

at  the  rate  of  an  office  visit. 
Washing  of  the  stomach,  or  stuffing. 
Washing,  forcing  by  pressure,  with 


$3        $5      $10      $25 


Washing  of  the  pleura 5 

Appendicitis 25 

Maternity  cases 10 


5 
10 
10 

5 
5 


25 
25 
25 

10 
10 


10        25 


10        25 


2 

5 

5 

5 

10 

25 

100 

250 

500  to  10,000 

25 

100 

500  to  10,000 

ORTHOPEDIC    FEES. 

Orthopedic  surgeons  very  generally  take  their 
chronic  cases  by  the  year.  They  will  charge  from 
$50  to  $100  per  year,  for  instance,  for  the  treat- 
ment of  a  case  of  Pott's  or  hip  disease.  In  such 
cases  they  call  only  as  often  as  they  think  neces- 
sary.   Of  course,  you  charge  a  patient  for  a  call  or 


Orthopedic  gymnasium. 


MEDICAL  FINANCE  127 

visit  when  you  advise  him  to  see  a  specialist,  and 
also  you  charge  for  your  visit  in  taking  part  in  a 
consultation. 

You  will  often  be  asked  as  a  hospital  interne  to 
sign  insurance  certificates.  In  such  cases  it  is  no 
more  than  justice  that  you  should  be  paid  for  your 
trouble.  The  charges  vary,  but  about  $1  per  hun- 
dred of  insurance  is  a  fair  fee.  Some  hospitals  will 
not  allow  you  to  charge  for  such  services. 

THE  FEE  FOB  PATHOLOGICAL.  WORK. 

Urine,  for  albumin  and  sugar,  Sl.OO. 

Urine,  complete,  quantitative  and  qualitative,  $3.0O-$5.00. 

Sputa,  $2.00-$5.00. 

Milk,  $3.00. 

Blood  complete,  $5.00. 

Pathological  specimens,  $5.00-$10.00. 

Wassermann  reaction,  $10.00-$15.00. 

FEES  FOR  RENDERING  ASSISTANCE  TO  OTHER  PHYSICIANS. 

For  giving  a  general  anaesthetic,  you  should  re- 
ceive at  least  $5 ;  in  some  instances,  $10.  For  a  spe- 
cialist in  anaesthesia,  the  price  varies  from  $25  up, 
although  many  take  cases  at  $10. 

For  assisting  in  a  labor  case,  the  fee  will  be 
from  $5  up,  depending  on  the  price  that  the  ac- 
coucheur receives,  and  on  the  amount  of  time  and 
labor  you  spend.  For  putting  on  forceps,  $5  to  $10, 
depending  again  on  circumstances.  When  a  spe> 
cialist  puts  on  forceps  or  delivers  a  difficult  case, 


128    BUILDING  A  PROFITABLE  PRACTICE 

the  price  varies  from  $25  to  $200,  depending  on  the 
diflficulty  and  the  ability  of  the  individual  to  meet 
the  expense. 

A  curetting,  $10  to  $25. 

Perineorrhaphy,  $10  to  $25. 

For  assisting  at  major  operations,  from  $10  to 
$100. 

A  single  ordinary  visit — the  price  that  the  prin- 
cipal receives  from  the  same  people. 

In  former  years  it  was  customary  for  physicians 
to  reciprocate  as  far  as  making  calls,  i.e.,  when  one 
could  not  attend  to  his  practice  for  any  reason,  a 
friend  looked  after  his  practice  and  the  favor  was 
returned  at  a  later  date.  Among  very  close  friends 
and  among  men  who  are  on  a  plane  as  far  as  ability, 
experience,  and  practice  are  concerned,  such  a  plan 
works  well,  but  it  has  often  been  the  cause  of  much 
bitter  feeling.  Such  an  arrangement  is  not  suitable 
for  a  beginner.  If  an  older  man  asks  you  to  do  it, 
do  it  with  the  distinct  understanding  that  it  is  to  be 
one-sided,  i.e.,  that  you  do  not  expect  any  return 
service.  As  the  chances  are,  there  will  be  little 
chance  of  such  reciprocation  on  his  part  for  years. 
On  the  other  hand,  if  he  accepts,  it  will  put  him 
under  obligation  to  you.  It  is  unfair  to  ask  a  young 
man  to  do  such  work  without  compensation.  If  the 
principal  has  left  town  for  a  day  or  less,  the  assist- 
ant should  have  all  of  the  full  fees  either  collected 
by  himself  or  by  the  principal,  if  possible  at  a  later 
date  also.  The  full  fee  from  ordinary  chance  calls 
while  the  principal  is  busy  at  a  case  should  go  to 


MEDICAL  FINANCE  1«9 

the  assistant.  If  the  principal  is  sick  or  has  gone 
away  for  any  reason,  it  is  well  to  have  an  arrange- 
ment whereby  half  the  fees  collected  then  or  later 
goes  to  the  assistant.  In  other  cases  from  $25  to 
$50  per  week  is  paid  outright  for  all  services,  includ- 
ing attendance  during  office  hours.  The  assistant 
does  his  own  work  in  the  meantime. 

When  you  deliver  a  woman  in  the  temporary 
absence  of  her  physician,  you  should  collect  one- 
third  of  the  total  fee  from  her,  or  later  from  the 
physician.  This  will  depend  on  whether  he  is  an  hon- 
orable man  or  not.  In  no  case  will  you  continue  with 
the  case  after  he  has  arrived.  If  you  do  not  deliver 
her  before  he  arrives,  then  a  smaller  fee  is  sufficient. 
In  every  such  case  notify  the  attending  physician 
within  a  few  hours,  that  you  have  delivered  the 
woman,  telling  him  that  you  did  not  collect  the  fee, 
or  otherwise.  Then  he  will  assume  the  responsi- 
bility of  collection  or  otherwise,  as  he  chooses. 

ATTENDING  OTHER  DOCTORS. 

From  the  time  of  Hippocrates,  and  even  before 
that,  it  has  been  almost  an  unwritten  law  that  phy- 
sicians should  treat  their  brother-physician  in  any 
part  of  the  world,  whether  they  were  known  per- 
sonally or  not,  free  of  charge.  This  favor  was  gen- 
erally extended  to  their  immediate  families.  Since 
the  advent  of  specialism,  it  has  been  continued,  and 
the  added  motive  has  been  that  such  a  physician, 
when  treated  by  a  specialist,  would  be  quite  likely  to 
return  the  favor  in  referred  work.    In  the  large 

9 


130    BUILDING  A  PROFITABLE  PRACTICE 

metropolitan  centres,  as  New  York  and  Chicago, 
there  is  a  feeling  on  the  part  of  many  leading  spe- 
cialists that  this  fraternal  favor  should,  in  part  at 
least,  cease  to  influence  them.  They  reason  that,  if 
they  treated  all  of  the  physicians  who  come  to  them 
from  all  parts,  the  greater  part  of  their  time  would 
be  consumed  without  compensation.  This  is  partic- 
ularly true  of  the  obstetricians.  They  say  that  all 
of  their  time  would  be  taken  up  delivering  doctors' 
and  students'  wives,  which  could  be  done  just  as 
well  by  others.  Those  devoting  their  time  to  in- 
ternal medicine  seldom  charge  any  fees.  The  fees 
in  any  case  are  nominal,  not  more  than  one-half  the 
customary  fee,  and  many  physicians  feel  more  inde- 
pendent and  better  satisfied  if  they  pay  something. 
In  the  past,  there  is  no  doubt  that  the  free  treat- 
ment of  the  families  of  physicians  and  their  rela- 
tives by  specialists  has  been  abused,  but  everyone 
who  is  in  close  touch  with  specialists  will  receive 
due  consideration.  Certainly,  the  man  who  does 
such  a  favor  for  you  should  receive  your  consulta- 
tion work.  Brother-practitioners  in  the  same  field 
are  always  willing  to  treat  their  confreres  and  fam- 
ilies. It  is  only  those  near  the  top  who  feel  that 
something  must  be  done  to  economize  their  time. 

If  a  consultant  be  called  from  another  city  his 
expenses  at  least  should  be  paid;  otherwise,  he 
would  be  a  moving  charity  organization. 

In  the  large  centres  there  is  a  growing  custom 
to  charge  physicians  for  medical  services  when  such 
physicians  are  not  engaged  in  active  practice.    This 


MEDICAL  FINANCE  131 

is  especially  true  of  laboratory  workers,  wealthy  re- 
tired physicians,  those  who  do  detail  work,  and  those 
who  make  a  living  in  any  way  outside  of  general 
practice. 

TREATING  DENTISTS,   ETC. 

Strictly  speaking,  dentistry  is  one  of  the  spe- 
cialties of  medicine,  and  dentists  should  be  accorded 
the  benefits  of  free  treatment  by  physicians.  In 
smaller  cities  this  is  to  some  extent  practical,  but 
in  the  larger  centres  there  is  generally  little  reci- 
procity. If  a  dentist  does  work  for  you  or  your 
family  free,  or  at  a  nominal  charge,  you  should  re- 
turn the  favor ;  otherwise,  one-half,  or  in  some  cases 
full  fees,  should  be  obtained.  Much  the  same  prin- 
ciples should  obtain  with  regard  to  pharmacists; 
but  here  the  instances  where  you  should  reduce  your 
fee  are  even  less  numerous  than  with  the  dentists. 

TREATING  CLERGYMEN,  ETC. 

As  a  general  rule,  if  a  clergyman  receives  a 
salary  or  perquisites  amounting  to  $100  a  month, 
he  should  pay  for  his  medical  treatment.  Those 
having  poor  charges,  or  young  curates  or  assist- 
ants, scarcely  receive  enough  to  keep  them  in  clothes 
and  are  deserving  of  your  charity.  The  help  in  the 
houses  of  the  clergy  should  pay  as  in  any  other 
house.  In  some  places  it  is  customary  to  charge  the 
clergy  half  rates.  If  the  custom  is  established,  you 
will  not  be  wise  in  being  the  first  to  break  it.    It  is 


132    BUILDING  A  PROFITABLE  PRACTICE 

seldom  that  free  treatment  of  the  well-to-do  clergy- 
will  bring  you  any  practice,  and  you  can  scarcely 
ever  convince  yourself  that  you  are  treating  them 
as  a  charity. 

Many  people  will  expect  free  advice  when  they 
pay  a  bill.  If  it  does  not  entail  too  much  work,  give 
it  to  them,  telling  them  to  return  if  not  better. 
Never  skip  a  day's  call  in  treating  a  patient  without 
telling  him  beforehand  that  you  are  going  to  do  this 
in  order  that  you  will  not  run  up  a  big  account,  and 
that  there  is  no  absolute  necessity  in  a  daily  call.  Of 
course,  tell  the  friends  to  call  you  if  there  is  any 
change  in  the  patient's  condition.  A  statement  of 
this  kind  is  always  appreciated  and  will  get  you  a 
reputation  of  not  making  useless  calls  with  needless 
expense. 

It  is  better  to  treat  colored  people  and  Italians 
in  their  own  houses,  unless  they  are  very  cleanly,  as 
it  makes  a  bad  impression  on  the  patients  to  have 
your  office  smell  like  a  dispensary  or  a  hovel. 

It  is  the  practice  of  experienced  physicians,  when 
called  to  treat  the  servants  of  the  household  of  which 
they  are  the  attending  physicians,  to  refrain  from 
charging  a  fee;  one  reason  is,  that  they  cannot 
charge  the  same  fee  down-stairs  as  up-stairs;  and 
the  discrimination  of  fees  would  be  apparent  to 
every  one.  As  a  beginner  you  should  charge  the 
servants  an  ordinary  fee,  as  your  up-stairs  prac- 
tice, wherein  you  could  charge  a  larger  fee,  is  some 
years  distant. 


MEDICAL  FINANCE  188 

FEES   IN  ACCIDENT   CASES. 

When  you  are  called  to  an  accident  case  make  a 
note  of  all  the  injuries,  describing  them  minutely. 
If  you  think  that  the  patient  has  a  good  case  for 
damages,  you  need  not  be  insistent  in  your  demand 
for  a  fee,  as  a  much  larger  fee  may  come  later.  Ad- 
vise a  settlement  of  the  claim  as  soon  as  you  are  ab- 
solutely certain  of  the  extent  of  the  damage  done 
and  the  prognosis  thereof.  A  fair  settlement  is 
better  for  you  and  for  the  patient. 

If  these  suits  are  for  more  than  $500  they  usually 
run  for  two  or  three  years,  and,  finally,  after  two 
or  three  days  in  court,  neither  the  patient  nor  your- 
self may  get  anything.  In  such  accident  cases  you 
should  see  the  patient  every  few  months,  so  that  you 
can  explain  that  he  has  been  under  observation  dur- 
ing this  period.  Make  a  note  each  time  that  he  con- 
sults you.  Charge  in  your  book  a  full  fee  for  each 
visit,  so  that  you  can  show  it  in  court  to  the  lawyer 
for  the  defense.  Explain  that  the  reason  you  have 
not  rendered  your  bill  is  because  you  were  not  yet 
through  with  the  case. 

In  rendering  your  bill,  after  such  trials,  add  a 
fee  of  at  least  $25  for  your  appearance  in  court. 
Generally,  in  preparing  the  case,  the  attorney  for 
the  patient  will  consult  you.  It  is  then  wise  to  have 
some  financial  arrangement  with  him  as  to  your  fee 
for  court  attendance.  Tell  him  your  time  is  money. 
This  must  be  carefully  done,  as  you  will  be  asked  by 
the  lawyer  for  the  defense  if  you  expect  to  be  paid 
for  your  testimony.    If  you  give  a  statement  to  a 


134    BUILDING  A  PROFITABLE  PRACTICE 

patient  that  you  have  treated  him  for  the  injury,  you 
will  be  compelled  to  go  to  court,  and  legally  you  can- 
not collect  more  than  a  witness  fee.  If  you  have 
suggested  the  name  of  a  lawyer  who  is  a  friend,  your 
fee  will  probably  be  assured.  On  the  other  hand, 
you  will  be  criticised  for  the  delay,  failure,  etc. 
Legally  you  are  compelled  to  go  to  court  and  testify 
by  virtue  of  being  served  with  a  subpoena,  but  prac- 
tically you  can  make  yourself  an  unfavorable  wit- 
ness. This,  of  course,  you  would  not  do,  but  most 
lawyers  care  little  for  your  interest  after  they  have 
secured  their  own  fees  or  verdict.  So  try  to  get  a 
definite  arrangement  in  this  matter  at,  say,  so  much 
a  day  in  court,  as  your  testimony  can  generally  be 
construed  as  expert  testimony.  In  some  cases  by 
giving  your  claim  to  the  same  lawyer  with  10  per 
cent,  commission  for  collection,  you  will  get  it,  where 
otherwise  it  would  be  lost.  When  the  case  is  called 
in  court,  have  an  arrangement  with  the  lawyer  that 
you  will  be  kept  posted  by  telephone  an  hour  before 
the  time  you  will  be  required.  In  this  way  you  will 
save  many  a  day's  waiting  in  court. 

As  a  general  rule  in  ordinary  accident  cases, 
whether  the  results  are  due  to  the  carelessness  of 
some  one  or  not,  it  is  just  as  well  to  be  paid  your 
fee  right  away,  as  in  any  other  case.  When  the  case 
comes  to  court,  you  will  be  more  likely  to  have  no 
trouble  in  getting  your  attendance  fee. 

Hospital  physicians  and  internes,  in  some  States, 
are  not  compelled  to  go  to  court  and  testify  as  to 
cases  observed  by  them  in  hospital  practice. 


MEDICAL  FINANCE  135 

CURBSTONE  PRESCRIPTIONS,  FREE  ADVICE,  ETC. 

Many  people  will  meet  you  out  in  a  store,  at  a 
sociable,  etc.,  and  will  say,  "I  am  suffering  from  so 
and  so,  what  do  you  think  I  ought  to  do?"  Don't 
be  in  a  hurry  to  convey  the  information ;  remember, 
it  cost  you  the  equivalent  of  $10,000  for  that  knowl- 
edge, and  never  give  it  gratis  without  some  good 
reason.  On  the  other  hand,  you  must  offend  no  one. 
When  such  a  question  is  asked,  say,  ''Well,  your 
symptoms  might  point  to  one  of  several  things,  and 
it  would  be  better  to  see  that  no  mistake  is  made  in 
diagnosis  by  having  an  examination. "  It  is  not  wise 
to  use  the  word  ''examination"  to  a  woman;  rather 
say,  "It  would  be  better  to  have  your  chest  exam- 
ined," etc.  These  statements  are  strictly  true,  be- 
cause you  will  only  give  half-hearted  information 
under  the  circumstances.  Yet,  strange  to  say,  you 
will  be  judged  just  as  severely  as  though  you  charged 
full  price  in  case  your  prescription  does  not  suc- 
ceed promptly. 

Remember,  never  offer  free  advice,  unless  spe- 
cially asked  for  and  unless  you  feel  obliged  to  do  so 
for  some  good  reason.  No  one  appreciates  anything 
that  they  have  not  asked  or  paid  for.  If  the  advice 
is  asked  for  it  is  somewhat  different.  Early  in  your 
practice  get  in  the  habit  of  regarding  your  every 
sentence  like  a  grocer  does  his  sugar  or  tea,  or  an 
artisan  does  his  time,  as  having  a  distinct  monetary 
value.  It  is  not  like  the  conversation  of  other  peo- 
ple, as  it  represents  a  heavy  investment.     If  you 


136    BUILDING  A  PROFITABLE  PRACTICE 

give  any  information  over  the  telephone  that  is 
equivalent  to  what  you  would  tell  the  patient  in  your 
office,  charge  an  office  fee.  If  you  think  some  one 
is  trying  to  get  a  free  telephone  consultation,  get 
behind  the  Delphic  answer  that  there  may  be  some- 
thing more  serious,  and  that  it  would  be  better  to 
have  you  see  the  patient. 

With  the  very  poor  all  of  these  general  fee 
charges  must  be  reduced.  Sometimes  you  can  avoid 
this  reduction  by  charging  a  full  fee  for  one  visit 
and  nothing  the  next,  and  so  on.  In  Dublin  it  is 
customary  to  pay  a  guinea  for  the  first  visit  and 
nothing  is  expected  for  the  next  two  or  three.  It  is 
a  good  scheme,  provided  people  would  not  take  un- 
due advantage. 

When  life  is  at  stake,  you  must  not  stop  to  con- 
sider whether  you  will  ever  be  thanked  for  your 
efforts,  to  say  nothing  of  a  financial  settlement. 

CHABfilNG  RICH  AND  POOR. 

Rich  people  will  frequently  complain  that  they 
should  not  pay  more  than  the  poor.  You  can  point 
out  that  the  law  values  their  life  more,  as  instanced 
in  the  higher  verdicts  for  the  accidental  death  of  a 
banker  as  compared  with  the  laborer.  If  he  is  worth 
more  dead  than  the  other,  it  should  certainly  cost 
more  to  save  his  life.  As  a  comparison,  it  might  be 
said  that  the  church  expects  a  larger  contribution 
from  its  rich  members  than  from  its  poorer  mem- 
bers, although  the  spiritual  welfare  of  one  is  as  im- 
portant as  the  other.    Again,  the  well-to-do  demand 


MEDICAL  FINANCE  137 

more  of  your  time  than  the  laborer  does.  Always 
and  in  any  case  think  first  of  the  patient's  welfare 
and  strive  for  his  rapid  recovery;  think  of  the 
financial  reward  as  an  after  consideration. 

In  setting  a  charge  for  a  major  surgical  opera- 
tion, one  of  the  most  noted  surgeons  in  this  country 
charges  10  per  cent,  of  a  man's  yearly  income.  In 
some  places,  the  rental  of  a  patient's  home  may 
serve  as  a  basis  for  the  charge  per  visit. 

In  the  city,  any  family  of  three  whose  regular 
total  income  is  $12  a  week,  cannot  be  considered  in 
the  pauper  class.  In  the  country,  this  rate  may  be 
as  low  as  $10  a  week. 


CHAPTEE  XIV. 

Collections. 

Office  work  is  generally  paid  in  cash.  With  ve- 
nereal patients  this  should  be  absolute,  as  even  your 
best  patients,  after  they  are  cured  of  these  diseases, 
will  dislike  to  pay  for  such  services.  Among  the 
Italians  it  is  customary  to  charge  a  lump  sum  for 
this  purpose,  payable  at  or  near  the  beginning  of 
treatment.  It  is  interesting  to  note  that  in  the  early 
part  of  the  century  the  fee  table  in  the  State  of 
New  York  was  $50  for  syphilis  and  $20  for  gonor- 
rhoea. One  can  explain  this  to  the  patient,  that  it 
will  require  a  long  time  to  treat,  with  frequent 
visits,  and  if  paid  right  down  he  will  not  hesitate  to 
come  as  often  as  you  direct;  otherwise,  he  will  not 
come  when  he  feels  better,  although  the  disease  may 
be  still  active. 

Venereal  diseases  are  not  very  satisfactory  to 
treat  at  best.  If  you  follow  the  ordinary  charge 
method,  then  it  is  well  to  keep  on  hand  pills  of  proto- 
iodide  or  some  other  mercurial  and  have  the  patient 
report  to  yourself  for  the  medicine.  In  like  manner 
the  irrigation  treatment  of  gonorrhoea,  while  it  is 
more  satisfactory,  will  bring  the  patient  back,  so 
that  you  can  observ^e  him  until  cured.  This  treat- 
ment of  patients  by  physical  methods  at  the  office 
should  be  carried  out  as  much  as  possible.    It  serves 

188 


COLLECTIONS  139 

to  bring  the  patient  back  and  keep  him  properly  ob- 
served. If  possible,  never  simply  say  to  a  patient, 
' '  Just  keep  right  on  the  same, ' '  when  he  reports  to 
you,  or  soon  he  will  get  tired  coming  back  and  pay- 
ing you  to  say,  '* continue  right  on."  Always  do 
something,  or  make  some  slight  suggestion  as  to 
treatment  or  diet. 

If  a  patient  walks  out  of  your  office  without  pay- 
ing you,  and  you  do  not  feel  like  asking  him  for  a 
fee  outright,  you  can  say:  ''Let  me  see,  what  is  your 
address  again?"  writing  it  on  a  pad  in  his  pres- 
ence; this  will  suggest  to  almost  anyone  that  you 
wish  to  be  paid. 

Race  frequently  makes  a  difference  in  fees.  From 
the  lower  class  of  Italians  you  will  seldom  be  able 
to  collect  more  than  a  dollar  a  visit.  If  they  ask 
your  advice  for  several  on  the  same  visit,  charge  a 
dollar  apiece.  They  always  pay  cash.  The  Ger- 
mans of  the  poorer  classes  will  appreciate  the  fact 
if  you  do  not  call  unless  it  be  absolutely  necessary. 
The  fees  are  a  little  less  than  for  other  nationalities, 
but  are  generally  paid  cash.  They  are  not  a  diffi- 
cult class  of  people  to  handle.  Among  Hebrews  you 
will  find  that,  if  the  disease  be  at  all  serious,  you 
can  scarcely  make  too  many  visits.  The  pay  is 
generally  safe.  The  peojjle  who  give  you  the  most 
trouble  in  collecting  your  fee  are  the  oily-tongued 
natives,  who  pay  you  in  compliments. 

The  treatment  of  injuries,  received  in  fights, 
should  be  paid  cash  at  the  time ;  you  will  seldom  get 
it  afterwards.    Don't  be  too  familiar  with  these  pa- 


140    BUILDING  A  PROFITABLE  PRACTICE 

tients  in  your  treatment,  or  they  will  presume  on 
your  good  nature.  Make  a  strong  effort  to  be  paid 
cash  at  all  times  by  strangers.  In  the  large  cities 
you  should  always  try  to  be  paid  at  every  visit,  un- 
less you  are  acquainted  with  the  people.  Under  any 
circumstances,  whether  you  know  the  people  to  be 
honest  or  not,  remember  that  a  bird  in  the  hand  is 
wortli  two  in  the  bush.  With  strangers  try  to  have 
a  financial  agreement  at  all  events  at  the  second 
call.  At  your  first  call,  after  having  finished  your 
work,  stand  up  in  the  middle  of  the  floor  and  slowly 
look  about,  twirling  your  hat  as  though  you  were 
waiting  for  some  one  to  come,  at  the  same  time  not 
saying  anything  for  a  few  minutes.  This  will  cause 
most  people  to  make  some  suggestion  as  to  pay- 
ment. If  they  fail  to  do  so,  speak  to  the  one  who 
sees  you  to  the  door,  saying,  ''Now,  Mr.  So-and-So, 
of  course  you  know  we  are  strangers,  and  it  is  cus- 
tomary to  have  some  financial  understanding,"  etc. 
It  is  seldom  that  such  a  statement  is  received  with 
resentment.  Whenever  a  patient  says,  "Shall  I 
pay  you  now  or  when  you  get  through?"  always 
answer,  "You  might  as  well  pay  now,  as  it  will  not 
be  so  hard  later,"  or  "Short  accounts  make  long 
friends,"  "It  will  avoid  making  a  trip  to  the  of- 
fice," etc.  You  do  not  know  how  long  any  case  may 
last,  and  it  is  better  to  get  as  much  on  account  as 
possible.  In  long  cases  always  try  to  get  something 
on  account  from  time  to  time,  even  though  you  are 
well  acquainted  with  the  people.  There  is  no  bill 
so  hard  for  most  people  to  pay  as  a  doctor's  bill. 


COLLECTIONS  141 

They  will  generally  say,  **He  does  not  need  it,  and 
can  wait  until  every  one  else  has  been  paid."  This 
is  unfair,  and,  no  matter  what  the  custom  has  been 
in  the  past,  if  you  want  to  advance  in  your  profes- 
sion, to  get  new  apparatus,  to  do  post-graduate  work, 
etc.,  you  must  get  paid,  and  paid  promptly.  Every 
day  your  money  is  out  is  sheer  loss.  You  would 
have  paid  6  per  cent,  at  least  for  that  money.  All 
these  things  you  can  explain  when  people  complain 
about  receiving  a  bill  from  you. 

SEND  YOUB  BILLS  REGULARLY. 

Some  one  will  say  that  people  will  resent  the  fre- 
quent sending  of  bills.  Nine-tenths  of  those  who 
resent  it  are  financially  bad  any  way,  and  the  sooner 
you  lose  them  as  patients  the  better  for  your  peace 
of  mind  and  for  your  pocketbook.  So  send  your 
bills  as  soon  as  you  have  finished  with  the  case.  If 
you  live  in  a  large  city,  you  should  send  bills  to 
most  of  your  patients  every  month.  The  dwellers 
in  large  cities  do  not  feel  the  same  moral  obliga- 
tion to  pay  bills  that  people  do  who  live  in  small 
communities.  There  is  no  odium  attached  to  them 
if  they  do  not  pay  their  bills.  They  can  go  to  the 
next  street  and  get  another  doctor  without  any 
trouble.  If  they  move  a  few  blocks,  they  may  never 
see  you  again.  They  do  not  get  nettled  easily  at 
the  sight  of  a  monthly  bill,  because  they  are  accus- 
tomed to  get  monthly  statements  from  all  of  their 
dealers.  In  fact,  many  like  it  because  it  shows  them 
where  they  stand  financially.     The  butchers  and 


142    BUILDING  A  PROFITABLE  PRACTICE 

bakers  expect  to  be  paid  every  month.  Why  should 
you  not  get  yours!  Your  future  prosperity  will  de- 
pend on  the  business  methods  that  you  install  in 
the  first  days  of  your  practice.  If  you  are  careless 
in  sending  bills,  either  on  account  of  being  too  busy 
or  afraid  of  injuring  somebody's  feelings,  you  will 
lose  a  large  part  of  your  income.  Anyone  who  does 
not  put  the  value  of  your  services  above  the  fact  that 
you  send  him  a  statement,  let  him  go  to  the  other 
doctor  and  you  will  be  glad  to  get  rid  of  him.  Those 
who  want  you  expect  to  pay  for  services  rendered, 
while  those  who  do  not  want  you  would  not  employ 
you,  even  if  you  offered  to  attend  them  free  of 
charge. 

Charge  for  your  services  and  charge  a  fair  fee. 
If  your  services  are  not  worth  the  regular  rate,  then 
say  so  and  take  less,  if  there  be  any  complaint ;  but 
do  not  underrate  your  services  by  reductions  which 
are  ridiculous  from  a  business  standpoint.  If  a 
grocer  or  butcher  reduced  his  account  every  time 
that  you  wished  to  settle  with  him,  what  would  you 
think  I  Certainly  that  his  goods  were  not  worth 
what  he  charged  for  them,  or  that  he  padded  his 
account  with  false  charges.  So  with  the  doctor. 
Wlien  you  have  made  so  many  visits,  charge  for  the 
full  number  of  visits ;  then,  if  you  think  the  patient 
cannot  afford  it,  deduct  what  you  think  proper  and 
make  a  statement  to  that  effect,  that  the  bill  is  re- 
duced to  such  and  such  amount.  The  sooner  after 
an  illness  that  a  bill  is  received,  the  less  it  seems. 
A  bill  sent  six  months  after  an  illness  comes  when 


Handy  arrangement  of  desk,  reference  books,  and  typewriter. 


COLLECTIONS  143 

all  of  the  tedious  details,  sufferings  and  anxiety 
are  forgetten,  so  many  of  the  doctor's  calls,  his 
night  visits,  his  hard  work,  etc.,  are  not  remembered. 
Whereas,  if  it  comes  in  soon  after  the  illness,  while 
these  things  are  fresh  in  the  mind  of  the  patient, 
it  seems  quite  small  and  reasonable. 

People  with  property  need  not  be  pushed  so  hard, 
but  the  sooner  your  bills  are  paid  by  all  the  better. 
Another  doctor  may  be  brought  into  the  family, 
their  business  may  be  suddenly  ruined,  they  may 
move  out  of  town  or  a  thousand  other  things  may 
happen  to  keep  your  money  forever  out  of  your 
pocket.  Besides,  if  they  pay,  they  will  feel  more 
free  to  call  you  if  anyone  else  in  the  family  is  taken 
ill.  Oftentimes  if  people  owe  a  bill  they  will  try  to 
get  along  through  minor  illnesses  by  the  use  of 
household  remedies ;  whereas,  if  the  bill  is  paid,  they 
will  send  for  a  physician.  In  case  another  account 
is  run  up  before  the  first  account  is  paid,  you  may 
have  to  reduce  the  total  bill.  You  may  find  that 
old  Doctor  Jones  never  sent  a  bill  in,  or  that  Doctor 
Smith  only  sends  his  account  in  once  a  year.  That 
should  make  no  difference  with  you;  you  are  of  a 
new  generation,  and  you  expect  to  make  a  little  more 
than  the  mere  existence  that  Smith  and  Jones  have 
derived  out  of  their  practices.  Even  your  best  fam- 
ilies should  get  a  bill  once  in  four  months. 

You  will  often  find  yourself  in  the  following  pre- 
dicament. You  will  treat  a  poor  family  for  quite 
a  long  case,  and  if  they  have  not  been  able  to  pay 
anything  on  account  the  bill  will  be  very  large,  so 


144    BUILDING  A  PROFITABLE  PRACTICE 

large  that  they  can  never  hope  to  pay  it.  Better 
state  the  full  amount  and  reduce  it  half  or  less,  so 
as  to  bring  it  within  their  means.  Many  times  you 
will  be  unable  to  get  anything  for  your  services,  be- 
cause the  people  are  too  poor.  Treat  these  poor 
people  just  as  considerately  as  your  good  patients. 
It  has  ever  been  the  privilege  of  our  profession  to 
minister  to  these  poor  unfortunates.  Generally  it 
is  better  to  treat  them  in  their  own  homes  unless 
they  can  come  cleanly  to  your  office.  You  will  be 
paid  in  gratitude,  which  is  often  better  than  the 
yellow  gold  of  some  of  your  wealthy  patients.  Do 
as  much  of  this  charity  work  in  your  earlier  days  as 
you  can,  as  you  will  get  the  experience  and  it  will 
serve  to  broaden  your  mind.  You  will  be  brought 
in  close  touch  with  this  human  nature  of  ours  and 
look  on  it  in  a  saner  light. 

Treat  those  whom  you  know  to  be  dead  beats. 
They  will  generally  praise  you  far  and  wide  as  long 
as  you  don't  press  them  for  money.  This  adver- 
tisement is  worth  as  much  as  money,  or  more  to 
you,  in  the  first  year  of  your  practice.  Besides,  you 
secure  the  experience,  which  is  quite  as  valuable. 
Try  to  get  something  from  them  on  account.  Like- 
wise, if  a  family  defrauds  you  once,  treat  them 
again,  but  try  not  to  trust  them,  as  they  will  repeat 
the  trick.  It  is  easy  to  ask  for  your  money  in  such 
a  case,  and  don't  be  bashful  or  the  people  will  cer- 
tainly take  advantage  of  you. 

There  is  much  reason  why  the  physician's  ac- 
count should  be  settled  first,  rather  than  last,  as  is 


COLLECTIONS  145 

often  the  case.  These  accounts  are  many  times  con- 
tracted during  periods  of  the  greatest  physical, 
mental  and  financial  distress  of  the  afflicted  family 
when  one's  higher  feelings  prompt  him  to  render 
sympathy,  as  well  as  his  services,  without  immediate 
thought  of  reward.  For  that  reason  he  should  be 
paid  first,  because  of  the  double  service  of  sym- 
pathy and  work  without  any  immediate  sign  of 
financial  return.  No  other  occupation  expects  any- 
thing but  prompt  pay  the  moment  the  work  is  done. 
This,  of  course,  supposes  that  you  are  giving  good 
service,  keeping  abreast  of  the  advances  in  the  pro- 
fession, and  that  you  give  your  patients  the  best 
service  of  which  you  are  capable. 

When  you  have  a  patient  whose  account  is  likely 
to  be  disputed  in  the  future  because  of  family  inter- 
ference or  other  reason,  it  is  a  good  plan  to  have 
him  sign  a  due  bill  as  follows : 

"  The  above  account  is  correct,  and  there  is  now  due 

upon  it  to  Dr the  sum  of " 

Signed 

Witness 

This  would  enable  your  estate  to  collect  your 
bills;  otherwise,  they  are  for  the  most  part  uncol- 
lectible. Furthermore,  in  the  event  of  the  death  of 
the  patient  owing  the  bill,  your  own  settlement  will 
be  much  easier.  The  time  to  have  such  a  statement 
made  is  when  all  of  your  services  are  vividly  im- 
pressed on  his  mind,  and  when  he  is  grateful  to  you. 
He  can  then  look  over  the  account  and  make  what 

10 


146    BUILDIXG  A  PROFITABLE  PRACTICE 

payment  he  can  and  acknowledge  the  remainder. 
No  honest  patient  will  refuse  to  sign  such  a  note, 
but  it  sometimes  requires  some  assurance  on  the 
part  of  the  average  doctor  to  suggest  it. 

While  your  monthly  bill  serves  to  keep  your  ac- 
counts well  in  hand,  at  the  same  time  it  constantly 
keeps  before  your  own  mind  the  fact  that  So-and-So 
owes  you.  There  will  always  be  some  people  who 
have  little  or  no  financial  conscience.  Some  are  slow 
pay  because  of  mere  forgetfulness  and  neglect,  and 
others  are  slow  pay  because  they  hope  to  escape 
paying  at  all.  It  is  always  much  cheaper  and  better 
all  round  for  you  to  collect  your  accounts  by  means 
of  letters  than  by  a  collector.  After  having  sent 
out  three  or  four  monthly  statements  and  you  be- 
lieve that  no  attention  is  being  paid  to  the  account, 
send  a  bill  every  two  weeks,  accompanied  by  a  polite 
note.  Be  careful  in  using  threatening  language,  as 
it  is  against  the  law,  and  you  might  be  sued  for  it 

If  these  measures  fail,  you  may  use  the  following 
series  of  letters,  as  suggested  by  Dr.  Taylor : 

FORMS   OF  COLLECTING   LETTERS. 
First,  Suggestive  Letters. 

(1)  An  early  settlement  of  this  account  will  be  appreciated. 

(2)  This  account  has  apparently  escaped  your  notioe.  Kindly 
send  cash  in  settlement. 

(3)  Knowing  how  promptly  you  usually  meet  your  obligations, 
I  presume  the  above  bill  has  escaped  your  attention. 

(4)  No  doubt  this  account,  which  is  past  due,  has  escaped  your 
notice.     Kindly  oblige  by  an  early  settlement. 

(5)  Your  attention  has  been  called  to  this  account  several 
times.    I  now  desire  to  doae  same  without  further  delav. 


COLLECTIONS  147 

These  will  bring  in  many  accounts — those  who  are  only  careless. 
The  next  set  are  more  stimulating  in  character. 

Second,  Argumentative  Letters. 

(6)  I  have  done  my  part.  Don't  you  think  you  should  now  do 
yours  ? 

(7)  I  have  sent  you  this  bill  several  times,  and  have  received 
no  reply.  Will  you  kindly  state  if  incorrect,  or  why  it  should  not 
be  paid? 

(8)  This  account  has  evidently  escaped  your  notice.  I  need 
money  to  meet  my  obligations,  and  while  I  do  not  wish  to  crowd 
you,  if  you  can  favor  me  with  a  settlement  it  will  be  appreciated. 

( 9 )  Being  greatly  in  need  of  money  I  am  compelled  to  ask  those 
who  are  indebted  to  me  to  please  call  and  settle  as  soon  as  they 
conveniently  can. 

According  to  my  books,  the  amount  of  your  indebtedness  fo  me 
is  $ 

I  do  not  wish  to  press  you,  but  if  you  will  render  me  the  assist- 
ance asked  it  will  be  appreciated. 

(10)  When  you  send  for  a  doctor  it  is  because  you  need  him 
and  expect  him  to  come.  When  he  sends  you  his  bill  it  is  because  he 
needs  your  assistance  and  expects  it. 

(11)  If  you  send  for  a  doctor  twice  in  succession  you  would 
be  in  great  need  of  him,  and  would  think  very  badly  of  him  if  he 
neglected  you  under  such  conditions.     This  is  your  second  bill. 

( 12 )  I  beg  to  remind  you  that  your  account  has  not  been  paid, 
and  is  now  past  due.  In  requesting  a  prompt  settlement  I  am  ask- 
ing no  more  of  you  than  my  creditors  ask  of  me.  Give  this  your 
prompt  attention  and  oblige. 

(13)  I  recognize,  by  experience,  that  in  the  vast  majority  of 
cases  liquidating  physicians'  accounts  is  a  matter  of  forgetf ulness ; 
but  figure  yourself  what  it  would  mean  to  the  physician  if  all  his 
patients  treated  him  the  same  way. 

(14)  If  there  is  a  genuine  mistake  in  this  bill,  or  appertaining 
to  it,  I  wish  to  know  it,  so  that  we  may  together  see  to  its 
being  rectified.  Never  forget  that  again  and  again  in  a  person's 
lifetime  credit  is  absolutely  necessary  to  tide  over  the  pressure  of 
circumstances.  Credit,  at  such  times,  is  cash.  Therefore,  as  a 
matter    simply   of   intelligent   foresight,   it  behooves   every   actual 


148    BUILDING  A  PROFITABLE  PRACTICE 

debtor  to  make  good  on  all  past  grantings  of  credit,  even  when 
small,  as  soon  as  possible. 

I,  therefore,  feel  that  you  will  not  let  any  putting-off  habit 
balk  your  good  intentions,  and  that  you  will  communicate  with  me 
with  reference  to  the  settlement  or  adjustment  of  this  account. 

You  will  seldom  have  to  go  beyond  this.  How- 
ever, there  may  be  a  few  desperate  cases  upon  which 
you  may  try  the  following: 

Third,  Urgent  Letters. 

(15)  It  again  becomes  necessary  for  me  to  request  a  settlement 
of  your  account  with  me.  I  am  willing  to  give  all  the  accommo- 
dation possible,  but  I  need  the  money  and  must  insist  on  an  early 
settlement. 

My  books  show  a  balance  against  you  of Please 

give  this  matter  your  early  attention,  and  oblige. 

(16)  The  bill  enclosed,  long  past  due,  amounting  to  $ , 

has  not  yet  been  paid  by  you.  It  is  to  your  interest  to  adjust  this 
claim  with  as  little  expense  as  possible,  and  avoid  any  unpleasant 
litigation;  hence  I  request  that  you  make  a  plain  statement  of 
what  you  can  and  will  do  regarding  this.  If  you  are  unable  to 
pay  in  full,  make  a  proposition  to  settle  on  the  installment  plan. 
This  you  certainly  can  arrange  if  you  are  so  inclined,  and  it  will 
prevent  expense  to  you. 

Before  finally  placing  an  account  out  for  collec- 
tion, try  two  or  more  of  the  following  letters.  It 
will  nearly  always  bring  a  settlement,  if  the  party 
has  the  money. 

FourtK  Drastic  Letters. 

( 17 )  Unless  I  hear  from  you  by this  bill  will 

be  placed  for  collection. 

(18)  As  you  have  not  given  the  matter  referred  to  in  my  pre- 
vious letters  your  attention,  I  must  now  inform  you  that  your  ac- 
count is  long  past  due,  and  I  cannot  afford  to  let  it  run  any  longer. 


COLLECTIONS  149 

If  the  same  is   not  paid  or  satisfactory  arrangements  made   for 

payment  of  the  same  on  or  before 19 , 

I  shall  take  steps  to  force  collection.     I  do  not  wish  to  make  you 
any  trouble  or  cost,  but  if  I  do  it  will  be  your  fault,  not  mine. 
The  amount  due  is  $ 

(19)  Several    demands   have   been   made   for   payment   of   this 

account,  and  unless  it  receives  attention  before 

19 ,  it  will  be  placed  in  the  hands  of  an  attorney  with  instruc- 
tions to  collect  with  costs. 

(20)  I  urge  confidential  settlement  as  preferable  to  court  room 
publicity. 

No  prudent  person  will  allow  judgment  and  costs  rendered 
against  him. 

An  opportunity  is  now  given  to  settle  this  account  before  it  gets 
into  court.  When  once  a  judgment  is  entered  all  defenses  are 
barred.    It  becomes  a  lien  on  all  property  owned  by  debtor. 

I  do  not  hesitate  to  garnishee  wages  or  bank  accounts,  and 
never  fail  to  use  every  legal  expedient  to  collect  claims. 

When  you  are  making  efforts  to  collect  your  ac- 
counts by  mail,  you  should  make  every  personal 
meeting  with  your  debtors  as  pleasant  and  agree- 
able as  possible,  showing  a  genuine,  hearty  interest 
in  their  welfare,  even  though  they  are  now  employ- 
ing another  doctor,  never  making  any  reference  to 
their  indebtedness  unless  they  themselves  speak 
about  it,  and  this  they  usually  will  do. 

Keep  your  accounts  so  that  you  can  tell  any  one 
the  exact  amount  of  his  account.  If  you  cannot  do 
this  for  any  reason,  let  it  reach  him  by  the  next 
mail.  Many  a  fee  is  lost  because  the  statement  of 
the  account  is  not  ready  when  the  patient  is  ready  to 
pay.  Convivial  friends  or  necessities  of  the  family 
often  make  him  forget  his  former  good  resolutions, 
and  you  may  never  get  the  fee  again. 


160    BUILDING  A  PROFITABLE  PRACTICE 

To  be  known  as  a  good  collector  is  a  good  term 
of  commendation  in  a  physician,  and  most  good  doc- 
tors are  good  collectors. 

In  some  occupations  it  is  easier  for  a  patient  to 
pay  at  one  time  of  the  year  than  at  another.  For 
instance,  farmers  devoting  themselves  to  a  special 
crop  of  cotton  or  wheat  have  the  bulk  of  their  money 
at  one  time  of  the  year,  i.e.,  when  they  have  sold 
their  crops.  Those  who  do  general  farming  usually 
have  money  coming  in  at  all  seasons. 

Mechanics,  clerks,  laborers  and  others  working 
for  wages  or  salary  receive  their  money  weekly  or 
monthly,  which  is  usually  spent  as  soon  as  the  week 
or  month  is  up.  It  is  bad  policy  to  allow  them  to  go 
much  behind,  as  even  though  they  can  scratch 
enough  to  pay  their  current  expenses,  they  can  sel- 
dom pay  back  bills. 

According  to  law,  accounts  are  uncollectible  if 
they  have  been  dormant  for  a  long  period.  This 
period  varies  in  different  States.  It  is  usually  from 
two  to  three  years.  You  should  try  to  keep  all  of 
your  accounts  alive.  This  is  done  by  managing  to 
get  some  new  entry  on  account ;  either  a  service  that 
you  perform  or  a  payment  made  by  the  debtor. 
This  revives  the  entire  account,  no  matter  how  old 
it  might  be,  and  the  statute  time  starts  again  as 
from  the  beginning. 

If  possible  get  a  debtor  to  write  you  a  letter  ac- 
knowledging your  services,  and  stating  his  inten- 
tion to  pay  your  bill.  You  can  sometimes  do  this  by 
advising  him  of  the  fact  that  he  has  doubtless  unin- 


COLLECTIONS  151 

tentionally  overlooked  your  bill.  This  letter  will 
be  of  great  value  to  you  should  he  at  any  future 
time  dispute  your  claim,  and  it  virtually  revivifies 
the  account. 

COLiiECTION  OF  DISPUTED  CLAIMS. 

In  most  States  claims  for  services  must  be  filed 
within  two  years.  You  must  prove  that  you  have 
been  employed  and  that  your  services  were  ac- 
cepted. Parents  and  guardians  are  responsible  for 
their  children  under  age.  You  must  show  in  court 
the  date  of  visits  and  the  amount  should  be  charged 
up  each  day  under  the  visit  mark.  This  is  not  al- 
ways insisted  upon.  It  is  a  wise  thing  to  put  down 
the  amount  charged  each  day  in  all  cases  where  you 
think  that  there  may  be  trouble  in  collecting. 

Again,  I  want  to  call  your  attention  to  the  fact 
that  if  you  use  a  visiting  list  you  must  not  write 
anything  concerning  the  disease  that  the  patient 
suffered  from  on  the  page  where  the  charge  is  made. 
Likewise,  in  a  card  index  you  cannot  legally  use  the 
one  side  for  the  patient's  history  and  the  other 
side  for  his  account,  as  it  could  not  be  presented  in 
court. 

When  the  patient  has  died  and  left  an  estate, 
you  file  the  bill  with  the  executors,  who  will  arrange 
for  its  payment.  If  the  patient  had  no  relatives  or 
executors,  you  file  your  claim  with  the  public  ad- 
ministrator, who  will  pay  you  if  there  is  anything 
left  after  the  undertaker's  bill  is  paid. 

When  you  have  attended  a  patient  through  his 


152    BUILDING  A  PROFITABLE  PRACTICE 

last  illness,  and  after  death  the  friends  come  to  you 
with  an  insurance  certificate  to  fill  out,  find  out  if 
the  friends  are  likely  to  pay  the  bill.  If  not,  take 
the  certificate  to  the  undertaker  and  both  of  you  can 
arrange  to  be  paid  as  soon  as  the  comjjany  will  pay 
the  claim.  In  some  instances  you  can  find  out  from 
the  company  the  precise  time  when  they  will  settle 
and  you  can  then  be  present. 

COLLECTION    AGENTS. 

Don't  deal  with  any  collection  agencies  requir- 
ing membership  fee,  or  that  require  you  to  sign  a 
note  or  promise  with  penalty.  Deal  only  on  a  basis 
of  commission  for  the  amount  collected.  This  varies 
from  10  per  cent,  in  the  case  of  attorneys  when  large 
accounts  are  collected,  to  25  per  cent,  for  small  ac- 
counts, such  as  are  handled  by  the  ordinary  collec- 
tor. It  is  very  difficult  to  get  an  honest  collector,  so 
don't  give  all  of  your  accounts  to  the  first  one  se- 
lected. 

In  collecting  accounts  in  law,  the  arbitrary  signs 
used  by  physicians  in  their  visiting  lists  are  not  of 
much  value.  In  collecting  accounts  after  death  of 
the  physician,  they  are  absolutely  valueless.  In 
any  event,  to  be  collectible  the  exact  charge  for  any 
service  should  be  put  down  with  the  word  *' visit" 
or  "office  call,"  or  for  whatever  the  work  done,  as 
*  *  operation, ' '  etc.  Furthermore,  it  must  be  put  down 
at  the  time,  or  within  the  day,  of  the  service;  all 
amounts  paid  must  be  credited  on  day  and  date. 
When  suit  for  collection  is  entered,  the  patient  often 


COLLECTIONS  153 

retaliates  with  charge  of  malpractice.  In  such  a  case 
the  Liability  Insurance  Company  will  not  only  de- 
fend you,  but  in  most  cases  get  a  judgment  for  you 
as  well.  Of  course,  judgments  may  not  be  collectible 
because  of  the  fact  that  the  debtor  does  not  own 
anything  tangiT)le. 

Except  with  big  bills  and  with  people  owning 
property  it  is  not  advisable  to  sue,  as  it  costs  more 
than  you  can  get.  With  bad  bills  it  is  better  to  settle 
for  half  and  close  the  account  in  any  manner,  be- 
cause a  patient  who  owes  you  will  keep  others  away. 
They  are  ashamed  to  meet  you,  and  if  they  see  you 
coming  along  the  street  will  cross  over  to  the  other 
side,  remarking  to  their  companion  that  they  do  not 
like  to  meet  you,  as  you  were  the  means  of  ahnost 
killing  their  Katie,  or  John,  etc.  If  they  are  in  the 
sick  room,  they  will  persuade  others  from  sending 
for  you  in  accidents,  etc.,  by  the  same  excuse.  In 
your  financial  dealings  endeavor  to  get  the  money 
without  appearing  unduly  anxious  to  get  it;  this  is 
a  nice  art.  If  you  are  absolutely  fair  and  honest  to 
every  one,  you  will  unconsciously  acquire  it.  Your 
losses  should  not  average  more  than  5  per  cent,  of 
your  returns. 

You  have  invested  a  capital  of  $10,000  at  the 
very  least.  Your  returns  from  this  will  vary.  In 
the  large  city  $500  is  a  fair  return  for  the  first  year. 
This  should  show  about  $800  better  each  year,  imtil 
$5000  or  $6000  is  reached.  The  number  of  men  mak- 
ing more  than  this  is  not  great,  and  they  are  well 
known.    If  at  the  end  of  ten  years  your  returns  are 


164    BUILDING  A  PROFITABLE  PRACTICE 

$9000,  you  are  the  exceptionally  successful  practi- 
tioner. 

RESPONSIBILITY  FOR  BILLS. 

Whenever  a  patient  employs  you,  or  allows  you 
to  treat  him,  he  is  responsible  for  the  fee.  The  pa- 
tient must  always  pay  the  fee  of  the  consultant,  even 
though  the  attending  physician  has  not  left  him 
under  the  impression  that  he  (the  patient)  must 
pay  him. 

A  parent  is  bound  to  pay  for  medical  services 
rendered  to  his  minor  children.  After  21  years  of 
age,  unless  some  special  order  is  given,  he  is  no 
more  responsible  than  a  stranger.  If  a  minor  is 
away  from  home  with  the  consent  of  the  father,  he 
(the  father)  must  pay  all  medical  bills.  If  the  chil- 
dren be  taken  away  from  the  father  by  the  mother 
against  his  wishes,  he  is  not  so  clearly  liable.  Like- 
wise, the  husband  is  liable  for  the  medical  bills  of 
his  wife,  even  though  he  is  not  living  with  her  at 
the  time.  When  asked  to  treat  a  prostitute,  en- 
deavor to  have  the  one  who  calls  you  made  respon- 
sible. 

The  master  is  not  responsible  for  the  medical 
attention  given  to  his  servant.  If  the  master  calls 
you,  then  he  is  responsible,  even  though  he  makes 
no  direct  promise  to  pay.  If  his  wife  calls  you  to 
attend  a  servant,  the  family  is  not  responsible,  even 
though  she  promises  to  pay  the  bill. 

In  case  of  ship  captains:  The  captain  is  respon- 
sible for  the  medical  services  rendered  to  the  sea- 


COLLECTIONS  155 

man  during  the  voyage,  or  until  the  seaman  is  dis- 
charged. If,  however,  the  injury  resulted  from 
culpable  negligence  or  maltreatment  by  the  officers 
of  the  vessel,  he  is  responsible  for  the  services  rend- 
ered until  the  man  is  well  again. 

When  you  are  called  by  anyone  to  attend  a  pa- 
tient, the  one  calling  you  is  not  bound  to  pay  the 
bill,  unless  he  states  that  he  will  pay  the  bill  at 
that  time,  without  any  ifs,  then,  of  course,  he  is 
responsible. 

Where  an  agent  of  a  corporation  orders  medical 
attention,  there  is  often  much  dispute. 

Railroad  companies  are  the  ones  where  there  is 
much  difficulty  in  getting  at  the  party  who  can  au- 
thoritatively order  medical  attention.  Inasmuch  as 
the  company  is  not  legally  obligated  to  render  such 
service,  one  must  get  authority  from  the  respon- 
sible parties.  The  President,  the  General  and  Divi- 
sion Superintendents  and  Manager  are  always  re- 
sponsible. In  some  cases  the  station  agent  is  author- 
ized to  provide  for  temporary  medical  services.  In 
cases  of  sudden  emergency,  the  conductor  may  call 
for  medical  help,  and  if  it  be  a  plain  case  the  bill  is 
usually  paid.  If,  however,  the  chief  officers  of  the 
railroad  company  ratify  the  contract  of  any  of  the 
officers  of  the  company  in  this  matter  the  bill  is  col- 
lectible. This  ratification  can  be  established  if  you 
communicate  with  the  chief  officer  by  registered  let- 
ter, informing  him  that  the  patient  is  under  your 
care  and  the  attendant  circumstances.  If  he  does 
not  repudiate  the  contract  and  pays  no  attention  to 


156    BUILDING  A  PROFITABLE  PRACTICE 

it,  and  it  can  be  proved  that  he  received  your  com- 
munication, then  the  company  is  responsible. 

Generally,  post-mortem  examinations  and  claims 
for  attending  paupers  are  settled  by  the  county 
officials. 

A  county  or  municipal  corporation,  such  as  a  hos- 
pital, is  not  liable  to  a  patient  for  unskillful  or  im- 
proper treatment  by  the  attending  physician. 

When  a  physician  employs  another  physician  to 
assist  him  he  is  entitled  to  recover  the  value  of  the 
services  of  the  assistant. 

A  specialist,  when  generally  known  as  such,  can 
always  secure  in  law  a  higher  fee  than  a  general 
practitioner  would  receive  for  the  same  kind  of 
work. 

In  some  States,  the  financial  standing  of  the  pa- 
tient may  make  for  a  higher  fee  than  is  customary. 
It  is  often  so  construed  in  the  case  of  claims  against 
an  estate,  but  seldom  in  the  case  of  living  patients. 

Even  if  you  fail  to  benefit  a  patient,  it  is  no  bar 
to  recovery  of  your  compensation,  unless  actual 
want  of  skill  be  specifically  shown.  Even  if  you 
have  been  incompetent  in  some  States,  that  is  no  bar 
to  recovery  of  compensation.  Of  course,  the  coun- 
terclaim for  damages  by  the  patient  would  partially 
or  totally  offset  such  claims. 

The  fees  of  expert  witnesses  are  usually  fixed  by 
the  judge  or  district  attorney. 

If  you  were  to  act  as  an  expert  witness  and  agreed 
with  the  client  that  you  were  to  receive  a  stipulated 
sum  for  your  services,  but  that,  if  your  testimony 


COLLECTIONS  157 

would  aid  him  in  receiving  a  verdict,  you  would 
then  receive  a  larger  sum,  the  whole  contract  is 
void.  It  seems  that  lawyers  can  do  this,  but  phy- 
sicians must  not  testify  in  this  manner.  When  a 
lawyer  contracts  with  an  expert,  he  cannot  legally 
charge  it  up  as  costs  of  the  case,  but,  according  to 
law,  should  pay  it  himself ;  this  is,  of  course,  rarely 
done. 

In  the  collection  of  claims,  many  States  do  not 
bar  irregular  and  unlicensed  practitioners  from  col- 
lecting claims.  The  Statute  of  Limitations  as  to 
the  validity  of  an  account  varies  in  different  States. 
In  many  States  each  new  payment  makes  the  whole 
account  date  from  that  time.  It  is  for  this  reason  a 
good  plan  in  managing  long  accounts  to  see  that 
they  are  carried  forward  as  a  new  account  for  a 
new  period  of  time,  either  by  a  consultation  or  visit, 
etc.,  or  else  by  a  note.  If  the  account  is  carried  for- 
ward, then  it  is  essential  that  the  debtor  should  see 
the  account  and  agree,  either  expressly  or  impliedly, 
as  to  the  correctness  of  the  new  balance.  If  the 
debtor  does  not  object  to  the  Statute  of  Limitations, 
of  course  one  may  get  a  judgment  that  will  hold. 
The  mere  fact  that  the  physician's  services  have 
been  accepted  and  rendered  is  sufficient  to  establish 
employment. 

In  some  States,  notably  New  York,  it  is  not  legal 
for  the  physician  to  testify  as  to  the  patient's  exact 
physical  condition,  but  he  may  testify  as  to  the 
number  of  visits,  examination,  prescriptions  and 
operations,  and  if  the  defendant  objects  to  his  de- 


168    BUILDING  A  PROFITABLE  PRACTICE 

scribing  them,  the  physician  may  testify  as  to  their 
value.  As  there  would  be  no  one  who  could  dispute 
this  claim  without  the  patient  on  his  part  revealing 
his  physical  condition,  there  is  no  great  hardship 
done.  On  the  other  hand,  should  he  enter  a  counter- 
claim, then  he  waives  the  question  of  secrecy.  In 
some  of  the  other  States  there  is  no  bar  raised  to 
full  testimony  as  to  condition,  operation,  etc. 

Books  of  account  are  of  variable  value.  In  New 
York,  the  physician's  account  book  is  admissible  if 
he  can  show  that  it  is  his  regular  account  book,  and 
that  no  one  except  himself  and  wife  made  any  en- 
tries. The  fact  that  patients  paid  bills  is  sufficient 
proof  that  his  account  book  is  properly  kept.  It  is 
generally  required  that  the  books  shown  as  evidence 
be  of  original  entry.  Each  item  must  be  charged 
separately  and  a  specific  sum  charged  for  each 
visit.  This  is  of  especial  import  where  an  operation 
was  performed. 

These  account  books,  to  be  admitted  as  evidence, 
must  not  contain  matters  that  pertain  to  any  infor- 
mation as  to  the  physical  condition  of  the  patient; 
otherwise,  they  come  under  the  Statute  of  Privi- 
leged Communications.  In  some  States  this  rule 
does  not  hold.  In  most  States  if  you  secure  a  judg- 
ment against  a  patient,  that  is  a  bar  against  subse- 
quent suit  on  his  part  for  malpractice. 

In  collecting  claims  from  estates  the  account 
must  be  presented  to  the  administrator  or  executor, 
usually  within  six  months — the  earlier  the  better. 
These  claims  should  be  sworn  to,  adding  that  you  are 


COLLECTIONS  159 

a  legally  qualified  practitioner,  and  that  the  claim  is 
just  and  now  due.  If  the  claim  is  rejected,  then 
within  three  months  you  should  bring  action  against 
the  administrator.  If  not,  there  is  great  danger  that 
it  will  be  barred.  The  order  of  collection  in  most 
States  is  as  follows:  (1)  funeral  expenses;  (2)  ex- 
penses of  administration;  (3)  expenses  of  past  ill- 
ness; (4)  judgments;  (5)  public  debts;  (6)  simple 
contract  liabilities.  What  constitutes  a  last  illness 
is  variously  determined  by  the  courts.  In  some 
States  the  doctor's  claim  will  fall  in  the  sixth  class. 
In  an  estate  it  is  not  permissible  to  state  the  na- 
ture of  the  illness  with  which  the  deceased  suffered. 
The  number  of  calls,  operations,  etc.,  may  be  men- 
tioned, and  that  is  all.  For  this  reason  it  is  always 
wise  to  settle  such  claims  out  of  court  if  possible. 


CHAPTER  XV. 

Bookkeeping. 

The  problem  of  keeping  your  accounts  is  one  not 
to  be  considered  lightly.  Perhaps  in  the  first  few 
months  of  your  practice  it  may  not  be  a  serious 
matter,  but  a  careless  habit  in  this  respect  at  this 
time  will  institute  a  system  of  leaks  that  will  amount 
to  thousands  of  dollars  in  after  years.  Carry  on 
your  business  as  any  other  business  man  does,  so 
that  you  can  tell  at  the  end  of  any  month  what  your 
receipts  are,  and  what  is  owing  to  you.  You  must 
post  your  books  every  night.  Get  the  habit  of  doing 
it  as  regularly  as  you  wind  your  watch.  Have  your 
books  in  such  order  that  you  can  give  a  statement 
of  an  account  within  a  few  minutes '  notice. 

Various  systems  are  in  vogue.  The  first  and 
simplest  method  is  one  of  using  the  visiting  list  as 
a  day  book.  These  visiting  lists  cost  $1.50;  they 
are  made  to  last  one  year,  for  those  who  have  small 
practices.  They  are  published  by  the  Medical  Rec- 
ord, by  Blakiston;  the  Medical  Council,  and  others. 
As  a  rule,  they  contain  much  other  information  of 
value  in  emergency,  such  as  the  limits  of  dosage,  an- 
tidotes for  poisons,  etc.  This  is  the  best  and  only 
practical  method  of  doing  business  and  keeping 
track  of  it.  Little  memorandum  books  are  usually 
lost  and  do  not  carry  accounts  back  far  enough  to 
be  of  much  value.    In  this  book  you  can  put  down 

160 


BOOKKEEPING  161 

at  the  beginning  of  the  week  the  names  of  all  of  your 
appointments  for  the  week  with  a  dot  in  the  day 
of  the  appointment,  and  then  fill  is  as  they  are 
made,  with  a  ''V"  for  visit,  or  **C"  for  office  con- 
sultations, as  they  occur.  Legally,  it  is  necessary 
to  put  down  alongside  of  the  ''V"  or  "C"  the  price 
charged,  and  it  must  be  done  at  the  time  of  the  con- 
sultation. It  is  also  a  good  plan  to  put  down  on  the 
opposite  page  the  receipts  and  also  the  prescrip- 
tions given.  Be  careful  not  to  write  the  diagnosis 
on  this  page.  At  the  end  of  the  month  these  ac- 
counts are  to  be  transferred  to  the  ledger.  Buy  a 
good  ledger,  costing  from  $3  to  $5.  As  to  the  system 
of  keeping  accounts  in  the  ledger,  you  can  make 
use  of  any  one  that  you  choose;  a  simple  way  is 
to  make  ten  lines  across  every  two  opposing  pages 
and  through  these  draw  twenty-five  lines.  This 
will  make  a  series  of  blocks,  twenty-five  in  number 
and  ten  in  depth. 

The  name  of  the  month  can  be  written  over  the 
tops  of  the  twenty-four  boxes.  This  wiU  give  ten  ac- 
counts, covering  a  period  of  two  years.  The  name 
and  address  are  written  in  the  first  box  to  the  left. 
You  should  have  an  index  in  the  front  of  the  book, 
or  else  paste  a  letter  index  on  the  edges  of  the  pages 
at  intervals  of  every  six  or  eight  pages. 

Put  the  receipts  and  the  debits  in  each  block, 
debits  above  and  collections  below,  and  a  check 
mark,  if  bill  be  sent  out. 

There  are  several  very  good  and  simple  systems 
of  bookkeeping  for  physicians.  Taylor's  system  is 
11 


162    BUILDING  A  PROFITABLE  PRACTICE 

much  in  vogue.  Much  money  may  be  spent  in  elab- 
orate systems,  but,  as  a  rule,  they  fall  into  dis- 
use ;  a  man  methodical  enough  to  employ  them  would 
devise  one  himself  in  any  event. 

Some  men  do  well  with  the  card  index  system, 
but  great  care  must  be  exercised  that  the  cards  are 
not  lost  and  that  prying  people  do  not  get  into  your 
accounts.  A  loose  leaf  ledger  system  is  quite  prac- 
tical. No  matter  how  hopeless  the  account  may 
seem,  never  throw  the  memorandum  away,  as  eight 
or  nine  years  later  some  one  may  call  and  pay  the 
biU. 

REFERENCES. 

"The  Physician  as  a  Business  Man,"  J.  J.  Taylor,  Medical 
World,   Philadelphia,   Pa. 

"  How  to  Collect  Physicians'  Accounts,"  same  author ;  "  Sys- 
tem of  Bookkeeping,"  same  author ;  "  The  Law  and  Its  Relations 
to  Physicians,"  A.  N.  Taylor,   Appleton  &   Co. 


CHAPTER  XVI. 

The  Law  and  the  Doctor. 

The  State  grants  you  the  license  to  practise  med- 
icine, absolves  you  from  jury  duty,  from  military 
service,  and  usually  grants  your  vehicle  the  right  of 
way  after  the  fire  department  and  postal  delivery 
service.  Because  of  this,  however,  you  are  not 
forced  to  treat  anyone  whom  you  do  not  wish.  You 
are  not  compelled  to  get  out  of  bed  at  night,  but 
you  should  do  so  unless  you  are  ill.  Once  you  do 
accept  attendance  on  a  patient,  however,  it  becomes 
your  duty  to  continue  the  treatment  and  to  call  as 
often  and  as  long  as  the  case  may  require. 

MALPRACTICE. 

If  a  patient  tells  you  not  to  call  unless  sent  for, 
and  anything  happens  that  the  case  does  not  do  well, 
you  are  not  responsible. 

The  principal  is  responsible  for  the  errors  of 
his  assistant  physician,  if  the  man  be  employed  as 
an  assistant.  If,  on  the  other  hand,  the  physician 
recommended  is  in  independent  practice  and  is  con- 
sidered to  be  a  man  of  average  ability,  then  the 
physician  recommending  him  will  not  be  respon- 
sible for  any  error  that  he  may  make.  If,  however, 
he  is  taking  care  of  the  practice  with  a  financial 
understanding  the  case  is  not  always  so  clear. 

163 


164    BUILDING  A  PROFITABLE  PRACTICE 

It  is  not  permissible  to  bring  a  layman  into  a 
case  under  the  guise  of  a  medical  assistant. 

In  examining  the  insane,  great  care  must  be  ex- 
ercised, as  these  patients  often  sue  the  physician 
when  they  get  out  of  the  asylum. 

If  in  the  physician's  best  judgment  it  is  advis- 
able to  withhold  from  a  patient  in  a  particular 
emergency  a  knowledge  of  the  danger  and  the  extent 
of  the  disease,  he  is  justified  in  so  doing.  A  patient 
suffering  from  a  felon  was  told  by  her  attending 
physician  that  her  hand  was  doing  well.  He  was 
not  held  to  have  incurred  any  liability,  even  though 
pain  and  destruction  of  a  portion  of  the  finger  en- 
sued. 

A  cause  for  action  in  any  case  for  malpractice 
does  not  fall  with  the  death  of  the  patient  or  phy- 
sician, or  if  previously  commenced,  may  be  con- 
tinued by  or  against  the  personal  representative  of 
the  deceased. 

Criminal  malpractice  is  based  on  criminal  intent 
or  gross  carelessness.  Instances  of  gross  careless- 
ness are  nowadays  relatively  rare. 

A  physician  who  administers  a  poisonous  drug 
while  he  is  intoxicated,  if  death  result  therefrom, 
is  guilty  of  manslaughter.  Legally  speaking,  no 
physician  has  the  right  to  terminate  human  life 
under  any  circumstances. 

Anyone  who  administers  to  a  pregnant  woman 
any  medicine  or  employs  an  instrument  or  means  to 
produce  abortion  commits  a  felony.  If  death  of  the 
mother  results,  it  is  generally  held  as  manslaughter. 


THE  LAW  AND  THE  DOCTOR  165 

Some  States  make  the  mother  guilty,  if  she  does 
these  things  Herself.  In  the  production  of  abortion, 
the  law  requires  the  concurrent  opinion  of  two  phy- 
sicians before  it  can  be  legally  done. 

Concealing  a  foetus,  i.e.,  destroying  a  foetus  after 
the  fifth  month,  may  be  a  criminal  offence.  In  large 
cities  the  body  is  habitually  burned  in  the  furnace; 
after  the  sixth  month,  it  is  better  to  see  that  it  is 
turned  over  to  an  undertaker. 

In  most  States,  you  are  not  allowed  to  disclose 
any  information  which  is  acquired  in  attending  a 
patient  in  a  professional  capacity  and  which  was 
necessary  for  you  in  order  to  act  in  that  capacity. 
The  construction  of  this  statute  goes  so  far  that  the 
courts  prevent  a  receiver  in  bankruptcy  from  taking 
your  books  as  a  basis  for  collection  if  they  contain 
references  to  disease  and  treatment.  As  stated  be- 
fore, it  also  negatives  their  value  in  the  collection 
of  claims  if  they  contain  any  such  information. 
Communications  had  for  the  purpose  of  doing  an 
unlawful  act  or  committing  a  crime  are  not  within 
the  meaning  of  the  law,  and  will  not  be  protected. 

In  a  criminal  abortion  case,  according  to  the  law, 
the  last  physician  in  attendance  on  the  patient  is 
presumed  to  be  the  guilty  one.  This  works  a  great 
hardship,  as  in  most  cases  the  abortion  is  done 
by  some  one  else.  Everyone  must  in  the  light  of 
charity  and  duty  take  the  chance  of  being  legally 
committed  when  life  is  at  stake,  and  he  would  be 
considered  a  white-livered  physician  who  would  re- 
fuse to  treat  such  a  case  where  there  is  no  institu- 


166    BUILDING  A  PROFITABLE  PRACTICE 

tion  to  take  care  of  her,  simply  because  of  the  law 
in  the  matter.  If  you  treat  such  a  case  and  feel  sure 
that  the  woman  will  perish  it  is  good  practice  to 
notify  the  coroner  and  have  him  take  her  ante-mor- 
tem statement.  In  States  where  there  is  no  coroner 
recognized  by  law,  then  the  medical  oflBcer  that  sup- 
plants him  should  be  notified. 

Contracts,  in  general,  are  of  two  kinds,  written 
or  oral.  An  oral  contract  is  just  as  binding  as  a 
written  contract,  but  it  is  not  so  easily  proved. 
"Whenever  a  doctor  undertakes  the  treatment  of  a 
patient,  certain  contracts  are  created  by  the  law 
founded  on  the  relation  of  the  physician  and  patient. 
In  undertaking  the  treatment  of  any  case,  your  con- 
tract implies  that  you  have  such  skill,  knowledge  and 
information  that  will  enable  you  to  properly  and 
judiciously  perform  the  duties  of  your  profession. 
It  is  not  supposed  that  you  possess  the  highest  de- 
gree of  knowledge  or  skill,  and  yet  it  must  conform 
to  the  ordinary  current  text-book  requirements  at 
that  time.  Much  more  is  expected  of  the  doctor 
practising  in  large  centres,  by  reason  of  his  oppor- 
tunities for  study,  etc.  This  is  especially  true  in 
surgical  work,  and  a  doctor  in  the  country,  who  is 
compelled  to  do  major  surgery,  is  not  culpable  if  he 
is  not  up  to  date  in  his  technique  and  diagnosis.  So 
the  law  lays  down  the  statement  that  his  knowledge 
should  be  that  of  the  average  skill  presented  by  doc- 
tors in  similar  localities.  Furthermore,  you  con- 
tract to  use  reasonable  care  and  diligence  in  the 
exercise  of  your  skill  and  application  of  knowl- 


THE  LAW  AND  THE  DOCTOR  167 

edge  in  each  case.  This  is  a  very  wide  and  almost 
indefinable  doctrine.  It  means  that  one  should  give 
as  much  care  to  a  case  as  most  other  physicians  do 
in  similar  circumstances.  For  instance,  one  who 
would  see  an  acute  pneumonia  once  or  twice  a  week 
would  not  fulfill  such  a  contract.  Your  refusal  to 
accept  assistance  of  other  doctors,  or  to  meet  them 
in  consultation,  does  not  necessarily  increase  your 
legal  responsibility.  You  furthermore  contract  to 
use  your  best  judgment  in  cases  of  doubt.  This  is 
of  particular  value  in  cases  where  one  cannot  come 
to  any  conclusion  in  diagnosis  or  treatment,  as  it 
enables  one  to  do  what  his  best  judgment  deems 
necessary.  It  is  so  broad  in  its  field  that  it  covers 
most  of  the  faux  pas  of  practice.  You  also  contract 
to  follow  the  usual  and  customary  modes  of  prac- 
tice that  are  upheld  by  the  consensus  of  opinion 
among  the  members  of  your  own  school  of  medicine. 
This  means  that  you  should  not  experiment  on  pa- 
tients. A  great  surgeon  may  do  this,  but  to  lesser 
lights  It  is  dangerous  ground.  It  is  also  held  that, 
unless  reasonable  and  necessary  instructions  are 
given  to  the  nurse,  and  should  injury  result  there- 
from, you  may  be  held  for  damages.  This  covers 
not  only  your  period  of  attendance,  but  that  of  con- 
valescence as  well.  For  this  reason,  when  a  patient 
leaves  a  hospital  against  the  ad\dce  of  the  physician, 
he  must  sign  a  card,  releasing  the  hospital  from  all 
damages. 

In  all  cases,  the  patient  must  follow  the  rules  and 
directions  laid  down  by  the  attending  physician; 


168    BUILDING  A  PROFITABLE  PRACTICE 

otherwise,  he  cannot  successfully  sue  for  malprac- 
tice. Ordinarily,  you  do  not  contract  to  cure  any- 
one; you  simply  render  the  best  services  that  you 
are  capable  of  doing.  Once  you  undertake  the  treat- 
ment, unless  you  make  some  special  arrangement 
at  the  beginning,  you  are  compelled  to  continue  your 
services  until  discharged,  or  until  the  patient  is  well. 
Of  course,  if  you  are  taken  ill,  or  are  ordered  away 
because  of  illness,  etc.,  you  are  not  responsible. 
Likewise,  once  you  are  called  to  make  a  visit  on  a 
case,  the  responsible  party  is  responsible  for  all  of 
the  future  visits  that  you  may  make  until  discharged, 
or  the  patient  is  well  again.  If  you  are  called  as  a 
physician,  you  may  oflBciate  as  a  surgeon  unless  there 
be  some  explicit  understanding  to  the  contrary. 
The  mere  fact  that  you  make  no  charge  and  receive 
no  pay  for  treating  a  case  does  not  in  any  way  affect 
your  contract  to  do  your  best.  The  same  amount  of 
skill  and  care  is  as  much  the  right  of  the  pauper  as 
the  millionaire.  You  may  decline  the  call  to  treat 
such  a  case,  but  once  you  undertake  the  treatment 
you  are  bound  just  as  much  as  though  you  were  paid 
thousands  of  dollars. 

REVOCATION  OF  LICENSE. 

The  grounds  for  revocation  of  a  license  by  the 
State  Board  of  Examiners  are  usually  stated,  as  for 
unprofessional,  dishonorable  and  immoral  conduct. 
It  is  not  legal  to  punish  a  duly  qualified  physician 
for  unprofessional  conduct,  such  as  advertising  as  a 
specialist  in  certain  diseases,  as  it  would  be  uncon- 


Postniorteni  Pathology  (Cattell). 

Bucket  method  of  opening  and  cleansing  intestines,  especially 
useful  in  private  autopsies. 


THE  LAW  AND  THE  DOCTOR  169 

stitutional.  While  it  is  against  the  Code,  still  it  is 
no  menace  to  public  welfare.  If  the  advertisement 
contained  false  statements,  made  to  deceive  people, 
then  it  would  be  dishonorable  as  well  as  unprofes- 
sional, and  could  be  considered  a  just  ground,  or 
one  who  poses  to  cure  all  cases  of  any  chronic  com- 
plaint would  fall  under  this  ban.  In  some  States, 
namely,  Georgia,  Kansas,  Kentucky,  Louisiana, 
Maryland,  Michigan,  Nebraska,  North  Carolina, 
Rhode  Island,  Virginia  and  Vermont,  a  physician, 
practising  medicine  unlawfully,  cannot  recover  a 
fee  for  his  services.  This  is  practically  true  in  all 
States. 

AUTOPSIES. 

As  a  hospital  physician  you  will  often  wish  an 
autopsy.  The  best  way  to  obtain  it  is  to  get  the 
written  consent  of  the  patient  or  mayhap  of  his 
nearest  relative  before  death.  If  you  cannot  get 
this,  you  may  make  it  a  coroner's  case,  on  the  plea 
that  you  do  not  know  what  was  the  cause  of  death. 
Hospital  authorities  do  not  like  this  procedure; 
otherwise,  you  must  get  the  consent  of  the  nearest 
relative.  The  order  of  giving  such  consent  is  as 
follows:  (1)  a  permission  signed  by  the  husband  or 
wife  of  deceased;  (2)  if  neither  suryives,  then  the 
children;  (3)  if  there  are  no  children,  then  the 
father;  next  the  mother,  then  brother  and  sister; 
(4)  after  that,  the  next  relative  according  to  the 
same  law  that  deals  with  the  distribution  of  the 
property. 


170    BUILDING  A  PROFITABLE  PRACTICE 

If  you  are  called  to  see  a  patient,  and  if  the 
patient  has  recovered  by  the  time  you  get  there, 
or  if  another  doctor  has  arrived  ahead  of  you,  with- 
out any  unnecessary  delay  on  your  part,  you  are  en- 
titled by  law  to  your  fee.  It  is  questionable  whether 
you  would  be  wise  in  demanding  a  fee  under  such 
conditions  unless  the  people  are  transients. 

STOPPING  VISITS. 

On  determining  when  to  stop  your  visits,  you  are 
only  asked  to  use  ordinary  judgment  and  care.  You 
may  terminate  this  obligation  by  giving  notice  of 
your  intention  to  quit  attending  him ;  otherwise,  you 
are  liable  to  the  patient  for  all  resulting  damages. 

MEDICAL.  DEFENCE. 

If  you  possess  any  property,  it  is  wise  to  be  in- 
sured against  suits  for  malpractice.  There  are  a 
number  of  companies  that  insure  one  against  such 
suits,  which  are  usually  cases  of  blackmail  pure  and 
simple.  The  companies  obligate  themselves  to  de- 
fend you  in  court  and  to  pay  $5000  damages  in  case 
of  award  by  jury.  Such  a  policy  usually  costs  $15. 
One  of  the  State  medical  societies,  notably  the  New 
York  State  Society,  undertakes  to  defend  its  mem- 
bers in  such  suits  free  of  charge.  Thus  far  they 
have  been  uniformly  successful  in  beating  off  these 
pirates.  By  the  very  nature  of  your  calling,  you 
are  exposed  to  a  form  of  blackmail  that  is  difficult 
to  defend.    I  refer  to  the  occasional  harpy  who  will 


THE  LAW  AND  THE  DOCTOR  171 

call  to  consult  you  ostensibly  but  in  reality  to  charge 
you  with  assault.  Happily,  such  occurrences  are 
rare.  If  you  have  a  bell,  quietly  summon  help,  in 
the  shape  of  a  servant  who  can  listen  to  the  con- 
versation, and  thus  you  can  protect  yourself.  Put 
on  a  bold  front  in  all  such  cases  and  you  will  find 
that  it  will  be  rare  that  such  charges  are  pressed. 
Preserve  such  a  character  in  your  every-day  life 
that  the  presumption  at  law  will  always  be  in  your 
favor. 

Suits  for  damages,  such  as  faulty  setting  of 
limb  and  other  errors,  are  becoming  much  more  fre- 
quent than  in  former  years.  Relatively  few  of  them 
are  successful,  but  it  is  worth  much  peace  of  mind 
to  be  insured  against  the  worries  of  such  actions,  if 
for  no  other  reason.  In  all  such  cases  it  is  incum- 
bent on  you  to  notify  the  insurance  company  im- 
mediately on  receipt  of  notice  of  any  such  suit. 
Failure  to  do  this  may  nullify  your  policy. 

REFERENCES. 

"  The  Law  in  Its  Relations  to  Physicians,"  by  A.  N.  Taylor, 
Appleton  &  Co. 

Purrington,  in  McLane  Hamilton's  Medico-Legal  System. 


CHAPTER  XVII. 

Professional.  Ethics. 

Pbofessional  ethics  began  with  Hippocrates. 
Later  on  it  was  elaborated  in  the  great  schools  of 
the  Middle  Ages,  particularly  at  Salerno  and  at 
Paris. 

In  the  eighteenth  century  Dr.  Percival,  an  Eng- 
lish physician,  wrote  a  series  of  letters  for  his  son 
on  entering  practice,  and  these  are  the  basis  of  the 
code  of  ethics  of  the  American  Medical  Associa- 
tion. The  code  is  an  arrow  that  shows  you  the  right 
path.  In  its  application  you  must  follow  the  golden 
rule,  and  always  apply  it  when  in  a  quandary.  Do 
unto  others  as  you  would  have  them  do  unto  you. 
Do  this  at  all  times,  whether  seen  or  unseen,  and 
you  will  be  rewarded  with  a  clear  conscience  that 
will  enable  you  to  look  anyone  in  the  face. 

CBITICISM  OF  OTHER  PHYSICIANS. 

Don't  listen  to  criticisms  of  other  doctors. 
Change  the  conversation  at  the  first  break.  On  the 
other  hand,  you  yourself  must  not  criticise  a  neigh- 
boring physician,  either  to  other  doctors  or  to  your 
patients ;  it  never  helps  j^ou.  It  is  a  well-known  law 
that  a  physician  who  speaks  disparagingly  of  an- 
other doctor  to  a  layman,  at  once  lowers  himself  in 
the  opinion  of  the  layman.    The  layman  may  not 

178 


PROFESSIONAL  ETHICS  178 

openly  voice  his  disapprobation,  but  he  always  forms 
the  opinion  that  the  man  who  speaks  is  narrow- 
minded.  A  physician  who  speaks  ill  of  another 
doctor  to  a  physician,  while  he  does  not  belittle  him- 
self in  the  eyes  of  the  physician  as  he  does  with  the 
layman,  still  prepares  for  himself  the  reputation  of 
a  kicker. 

The  people  who  listen  with  greedy  ears  to  your 
denunciation  will  be  the  first  to  do  the  same  thing 
with  regard  to  yourself.  Criticism  of  this  kind  be- 
littles anyone  and  always  suggests  professional 
jealousy.  It  indicates  small-mindedness.  This  is 
true,  even  though  you  are  positively  certain  that 
the  doctor  has  handled  a  case  badly.  The  day  when 
a  doctor  could  come  into  a  sick  room  and  throw  out 
of  the  window  all  of  the  medicine  prescribed  by  his 
predecessor,  with  the  remark  that  these  things  were 
worse  than  poison,  etc.,  is  happily  past. 

Few  men  take  themselves  so  seriously  nowadays, 
and  they  are  either  knaves  or  fools.  The  more  gen- 
eral membership  in  medical  societies  has  made  this 
well-nigh  impossible. 

Some  men  will  not  say  anything  against  a  brother 
physician,  but  will  give  a  shrug  of  the  shoulder  or 
an  upward  look,  a  cynical  laugh,  etc.,  whenever  his 
name  is  mentioned.  This  is  quite  as  bad  as  saying 
mean  things  concerning  him.  Avoid  it.  Go  right 
on  with  your  case  when  another  doctor's  faults  and 
sins  are  mentioned,  and  say  nothing;  if  you  cannot 
defend  him,  say,  "Well,  I  don't  know  anything  about 
him."     Defend  him,  if  it  can  be  done.     Finally, 


174    BUILDING  A  PROFITABLE  PRACTICE 

medical  etiquette  can  always  be  invoked  in  favor  of 
courtesy  and  consideration  to  a  colleague,  but  must 
never  be  allowed  to  prejudice  the  health  or  lives  of 
patients. 

If  a  neighboring  physician  has  treated  you  badly, 
kindly  remember,  that  perhaps  half  of  the  occur- 
rence has  been  exaggerated.  Make  it  a  point  to  call 
on  him  and  find  out  the  truth  or  falsity  of  the  mat- 
ter. If  he  is  not  guilty,  all  will  be  plain  sailing. 
If  he  is  guilty  and  denies  it,  as  he  almost  certainly 
will,  he  will  at  least  be  more  careful  in  his  state- 
ments concerning  you  in  the  future,  and  this  will 
be  of  financial  gain,  sufficient  to  pay  for  your  time 
in  calling  on  him.  The  better  physicians  know  one 
another,  the  less  complaint  there  is  of  unprofes- 
sional conduct. 

One  does  not  like  to  meet  the  man  he  has  in- 
jured. The  corollary  to  that  rule  is  to  see  your 
brother  practitioners  often,  and  they  will  be  careful 
not  to  play  the  pirate  with  your  cases. 

Do  not  be  too  suspicious  of  your  neighboring 
physician,  to  whom  one  or  two  ladies  have  gone  after 
vainly  asking  you  to  commit  abortion.  They  may 
have  abortions  performed  by  some  one  else,  after 
vainly  asking  him  as  they  did  you,  and  for  shame, 
supposed  merit  or  other  reasons  preferred  to  have 
him  curette  them  or  otherwise  treat  them  instead  of 
having  yourself.  There  is  a  great  temptation  to 
blame  him,  but  it  is  well  to  question  oneself,  if  you 
might  not  have  been  the  unconscious  victim  of  some 
one  else's  thoughts  under  similar  conditions. 


PROFESSIONAL  ETHICS  176 

DISMISSAL  FROM  A  CASE. 

Some  fine  morning  you  will  find  a  note  under  tlie 
door,  informing  you  that  Mrs.  Jones,  whom  you 
have  been  treating  for  the  past  three  or  four  days, 
will  not  need  your  services  any  longer,  because  her 
old  family  physician  dropped  in  and  will  look  after 
the  case  in  the  future.  This  will  be  your  first  great 
discomfiture.  Don't  mope  over  it.  It  has  come  to 
all  of  us ;  it  is  a  necessary  evil,  otherwise  we  would 
all  become  too  great  in  our  own  opinion.  If  none  of 
us  lost  any  patients  we  would  soon  be  so  busy  that 
we  could  not  attend  to  a  fraction  of  our  practices. 

When  after  such  a  notice  you  meet  the  people  on 
the  street,  do  not  look  on  the  other  side,  but  boldly 
go  up  to  them  and  ask  after  the  patient.  Tell  them 
that  you  are  interested  in  the  patient.  Do  not  say 
anything  against  the  other  doctor,  but  wish  them 
"good  luck."  You  will  be  surprised  at  the  reaction 
in  your  favor,  and  they  will  not  continue  telling 
every  one  how  the  patient  would  have  died  if  Dr. 
So-and-So  had  not  been  called  in.  No  one  can  keep 
up  a  fight  long  against  graciousness. 

WHAT  CASES  YOU  MAY  TAKE  IN  THE  OFFICE. 

1.  Any  case,  no  matter  who  the  family  physician 
may  be,  that  comes  first  to  your  office  you  may  treat, 
provided  that  you  have  not  treated  him  any  time  at 
the  request  of  another  physician. 

Now,  let  us  suppose  that  you  are  called  to  attend 
a  case  where  the  regular  attendant  has  been  called, 


176    BUILDING  A  PROFITABLE  PRACTICE 

but,  having  failed  to  arrive,  the  people  sent  for  you, 
the  nearest  doctor.  Treat  the  emergency.  Avoid 
making  any  positive  statement  of  etiology,  diagno- 
sis, or  prognosis,  until  you  have  learned  what  the 
other  doctor  has  said.  If  you  cannot  confirm  his 
views,  don't  make  any  positive  statements. 

Collect  your  fee  on  the  spot,  and  do  not  charge 
lightly  in  such  cases.  This  will  prevent  them  trying 
to  tempt  you  to  take  the  case. 

It  is  customary  to  leave  a  note  at  the  patient's 
house,  to  be  given  to  the  physician  on  his  arrival, 
explaining  what  you  found  and  what  you  did.  Li 
default  of  this,  communicate  with  him  as  soon  as  you 
reach  home. 

It  is  a  nice  point  to  decide  whether  you  may  take 
a  case  in  that  family  afterwards.  In  most  cases 
there  is  no  reason  that  you  should  refuse  such  cases 
if  you  feel  that  you  have  been  scrupulously  honest. 
Don't  treat  the  patient  within  at  least  six  months 
except  at  the  request  of  the  attending  physician. 

If  the  doctor  arrives  before  you  are  through  with 
the  case,  turn  it  over  to  him  immediately  on  his  ar- 
rival and  leave  at  once,  unless  he  request  you  to  stay. 
He  should  then  see  that  you  are  paid  before  leaving. 
If  he  does  not,  speak  to  him  about  it  that  same  day. 

Do  not  tell  the  people  to  let  you  know  in  a  day 
or  so  how  the  case  is  getting  along.  Don't  ask  after 
the  patient  at  any  future  time,  because  the  doctor 
will  surely  hear  of  your  request  and  will  feel  sus- 
picious of  your  motives.  Eemember  always  that 
ours  is  the  most  suspicious  ( ?)  profession  under  the 


PROFESSIONAL  ETHICS  177 

sTin.  The  people  may  importune  you  to  take  the 
case ;  this  you  must  refuse  to  do,  although  after  some 
months  you  may  take  another  case  in  the  same  fam- 
ily, if  they  ask  you. 

The  obstetric  cases  will  be  the  hardest  ones  to 
avoid  continuing.  But  firmness  is  more  important 
here  than  anywhere  else,  because  the  attending  phy- 
sician has  had  the  case  in  his  mind  for  a  long  time 
and  has  given  it  more  thought  than  he  will  ever  be 
paid  for.  If  you  do  not  know  the  doctor,  collect 
at  once.  In  case  the  other  physician  has  turned  the 
case  or  his  practice  over  to  an  assistant,  your  obli- 
gation to  withdraw  from  the  case  is  not  so  clearly 
cut. 

The  Code  of  Ethics  suggests  that  whenever  a 
physician  is  called  to  the  patient  of  another  phy- 
sician during  the  enforced  absence  of  that  physi- 
cian, through  illness  or  otherwise,  the  case  should 
be  relinquished  on  the  return  of  the  latter.  In  large 
cities  this  section  of  the  code  is  rarely  observed. 
The  patients  will  not  permit  it,  and  the  young  man 
must  have  some  opportunity  to  get  a  practice. 

2.  The  patient  has  a  family  physician,  but  has 
not  sent  for  him,  and  he  is  not  under  treatment  at 
the  present  time.  You  are  entitled  to  treat  him 
without  notification  of  any  kind.  No  one  owns  pa- 
tients in  any  sense.  If  the  family  doctor  feels  bad 
about  it,  because  he  has  done  so  many  things  for 
the  patient  without  getting  or  asking  compensation, 
that  is  his  fault.  Ingratitude  is  the  rule ;  so  do  not 
count  on  favors  holding  patients  for  you. 

12 


178    BUILDING  A  PROFITABLE  PRACTICE 

The  trouble  between  physicians  generally  arises 
from  the  fact  that  patients,  either  by  accident  or  by 
design,  will  often  change  physicians.  The  one  who 
is  dismissed  or  loses  the  case  is  piqued  and  often 
vents  his  spleen  on  his  brother  practitioner.  This 
is  an  unfortunate  accompaniment  of  the  profession, 
and  one  must  learn  to  bear  such  rebuffs  with  equa- 
nimity and  not  to  charge  the  fault  to  the  other  doctor. 
It  should  spell  study,  work  and  diplomacy  for  you 
rather  than  jealousy,  because  you  cannot  measure 
up  to  the  other  man. 

3.  When  called  to  a  case  where  another  doc- 
tor has  been  employed.  Generally  when  the  call 
comes,  you  will  not  have  an  opportunity  to  find  out 
if  there  is  another  doctor  caring  for  the  patient. 
When  you  arrive,  if  you  see  that  the  patient  has 
been  ill  for  a  few  days,  question  him  as  to  what 
medicines  he  has  taken.  If  he  has  not  taken  any, 
it  is  quite  likely  that  he  has  not  had  another  physi- 
cian attending  him.  If  he  tells  you  that  he  has  had 
another  doctor,  find  out  his  name  and  the  reason  for 
his  dismissal.  The  people  will  tell  you  this  without 
any  questioning  on  your  part.  Ask  if  he  has  been 
dismissed. 

When  you  are  sunomoned  to  such  a  case  after  the 
discharge  of  a  colleague,  don't  go  into  the  room  with 
a  wise  shake  of  the  head  and  serious  mien,  emitting 
deep  sighs  at  short  intervals  and  then  informing 
the  parents  sadly  that,  if  they  had  called  you  sooner, 
something  might  be  done,  or  ''you  called  me  just  in 
time,"  or  trash  of  that  sort.     The  laity  will  say 


PROFESSIONAL  ETHICS  179 

this  themselves,  but  don't  you  make  any  such  state- 
ment if  another  doctor  has  been  attending  the  case. 
The  cases  where  such  a  statement  would  be  true  are 
probably  few  and  far  between.  When  such  a  state- 
ment comes  back  to  the  ears  of  the  first  physician,  it 
always  breeds  ill-will  of  a  lasting  character. 

You  must  remember  that  anyone  has  a  right  to 
change  doctors  as  often  as  they  feel  like  doing  so. 
They  view  your  employment  the  same  as  they  would 
any  other  mechanic,  while  you  are  apt  to  think  that 
you  have  some  superior  right  and  ought  not  to  be 
discharged.  There  is  always  a  cause,  whether  the 
cause  be  that  the  patient  is  not  making  progress 
fast  enough  to  suit  the  friends  or  some  neighbor,  or 
relatives  insist  on  having  their  own  doctor;  in  any 
case,  it  makes  little  difference  to  you.  They  have 
lost  confidence  in  you  and  you  consequently  feel  un- 
comfortable in  going  into  any  house  when  the  pre- 
siding spirit  feels  that  way.  When  such  a  feeling 
of  antagonism  exists,  it  is  far  better  for  you  that 
people  change  doctors,  although  you  should  not  sug- 
gest it.  So,  when  such  a  notice  comes,  let  it  be  an 
incentive  to  study  rather  than  to  blame  some  other 
doctor.  If  you  had  the  attainments,  either  profes- 
sional or  personal,  the  other  man  would  not  get  the 
case.  On  the  other  side,  some  day  the  tables  will  be 
turned,  and  you  will  be  the  fortunate  one  riding  into 
the  case. 

As  a  matter  of  fact,  in  chronic  and  subacute  dis- 
eases, the  change  of  doctors  often  works  improve- 


180    BUILDING  A  PROFITABLE  PRACTICE 

ment  and  perhaps  cure  in  the  patient.  Aside  from 
the  psychological  effect,  which  is  by  no  means  to 
be  despised  because  of  the  new  hope  that  is  enkin- 
dled in  the  patient's  mind,  often  a  newcomer  sees 
the  case  from  an  entirely  new  standpoint,  being 
free  from  the  influences  and  prejudices  that  are 
often  present  in  one  who  sees  a  case  from  the  be- 
ginning when  the  onset  was  such  that  it  would  mis- 
lead anyone. 

It  is  taught  that  under  such  circumstances  the 
physician  who  was  called  in  should  direct  that  the 
former  attendant  be  discharged,  before  he  takes 
the  case,  and  that  he  should  suggest  that  he  be  paid. 
In  large  centres,  this  rule  is  not  so  strictly  applic- 
able, and  many  busy  men  pay  no  attention  to  it. 
They  claim  that  it  works  a  hardship  on  them  to  go 
out  on  such  a  call  and  climb  seventy  or  one  hundred 
steps  and  not  receive  compensation  therefor,  unless 
the  people  choose  to  send  a  messenger  out  at  once 
to  inform  the  first  physician  and  pay  him.  It  is  to 
the  advantage  of  the  second  man  to  see  that  this  is 
done,  because  it  prevents  the  people  from  changing 
their  minds  if  his  diagnosis  happens  to  be  the  same 
as  the  first  doctor's.  It  also  saves  the  first  doctor 
a  disagreeable  half  hour  and  a  brooding  day,  if, 
after  he  has  walked  a  mile  or  two  to  the  sick  man's 
residence,  he  is  met  at  the  door  by  a  rebuff  and  pos- 
sibly a  remark  that  the  patient  would  have  died  if 
he  had  continued  calling. 

On  the  other  hand,  if  the  people  say  that  they 
only  wish  your  opinion,  to  corroborate  or  not  that 


PROFESSIONAL  ETHICS  181 

of  the  other  doctor,  one  of  two  courses  is  open  to 
you:  (1)  to  refuse  to  examine  or  give  an  opinion, 
except  in  consultation,  explaining  that  it  is  against 
the  law  of  medical  ethics  to  do  so;  or  (2)  you  may 
give  a  mere  non-committal  statement,  collect  your 
fee  and  tell  the  doctor  about  it  as  soon  as  you  reach 
home.  In  case  you  have  been  called  to  take  the  case, 
defend  him  as  much  as  you  can;  if  you  cannot,  do 
not  by  action  or  word  show  any  interest  in  the  mat- 
ter. This  is  the  rock  on  which  nearly  all  the  friend- 
ships between  physicians  are  wrecked.  The  people 
and  patient  will  at  this  time  multiply  a  hundredfold 
tEe  slightest  allusion  or  shrug  on  your  part.  They 
will  dream  what  they  think  you  ought  to  have  said, 
then,  figuratively  speaking,  put  it  in  your  mouth. 
All  of  this  will  surely  come  to  the  ears  of  the  first 
physician,  who  will  generally  feel  bitter  toward  you 
if  you  do  not  explain  the  situation  to  him. 

In  such  a  case,  never  criticise  the  other  doctor's 
work,  but  it  is  well,  if  you  find  a  lacerated  cervix  or 
perineum  at  labor,  to  state  the  fact  before  you  de- 
liver the  patient;  otherwise,  you  will  be  blamed  for 
it.  You  can  explain  that  each  labor  always  opens 
up  the  old  scars.  Let  us  suppose  that  you  take  the 
case.  Explain  that  the  doctor  has  done  the  best  he 
could,  and  suggest  that  he  be  paid  at  once,  and  that 
as  a  consequence  there  will  be  no  hard  feelings  on 
his  part. 

The  first  thing  you  do  on  going  home  after  such 
a  call,  is  to  communicate  with  the  doctor,  explaining 


182    BUILDING  A  PROFITABLE  PRACTICE 

matters,  and  find  out  if  he  has  been  paid.  You  will 
find  that,  as  a  rule,  he  will  appreciate  this  little 
compliment,  even  though  he  has  not  been  friendly 
before.  My  own  experience  has  been  that  in  such 
cases  the  second  one  called  in  is  seldom  paid.  So 
be  sure  and  collect  your  fee  at  every  visit.  You  are 
in  a  strong  position  and  can  demand  it,  as  they  must 
appreciate  your  being  called  as  a  second  choice.  If 
they  do  not,  they  are  more  than  likely  in  the  dead 
beat  class. 

There  is  a  species  of  individual,  usually  a  woman, 
who  likes  to  make  ill-feeling  between  doctors.  She 
will  tell  one  man  that  another  doctor  said  so  and  so 
derogatory  to  his  ability,  etc.,  and  this  serves  to  stir 
up  a  feeling  of  resentment  which  causes  him  to  as- 
sail in  every  possible  way  his  confrere,  who  is  en- 
tirely innocent.  Recriminations  follow,  and  both 
are  at  each  other's  throat.  It  is  so  easy  to  fan  the 
fuel  of  this  sort  of  enmity  that  all  true  physicians 
should  strive  to  snuff  it  out  at  its  inception,  and  the 
surest  way  to  stop  it,  even  though  there  be  some 
truth  in  the  original  firebrand,  is  to  have  a  few  min- 
utes'  conversation. 

ETHICS    OF    INSUBANCE    EXAMINERS. 

If  you  are  employed  as  an  examining  physician 
by  any  insurance  company,  you  should  not  examine 
an  accident  case  without  communicating  with  the 
family  physician  and  having  him  present  at  the  ex- 
amination. 


PROFESSIONAL  ETHICS  183 

ETHICS  OF  SUBSTITUTE. 

If  you  receive  a  call  through  another  doctor's 
office  while  he  is  out  or  engaged,  you  should  notify 
him  as  soon  as  you  have  made  the  call.  Don't  see 
the  patient  again  without  his  sending  you.  He  may 
not  volubly  object  to  your  going,  but  unless  he  spe- 
cifically sends  you  do  not  go,  as  the  case  belongs  to 
him.  If  his  office  had  not  delegated  you  to  go  on 
the  call,  some  one  else  would  have  been  sent.  There- 
fore, you  have  no  right  to  presume  as  a  fact  that  the 
patient  was  not  one  of  his  regular  patients  even 
though  he  never  saw  the  patient  before.  His 
reputation  achieved  after  years  of  labor  is  what 
brought  the  call  originally,  and  you  are  taking  his 
place  for  the  moment  only.  The  people  will  very 
likely  wish  you  to  continue.  Do  not  do  so,  thinking 
that  it  will  not  be  known.  Everything  comes  to  the 
ears  of  an  old  practitioner  when  he  wishes  to  listen. 
Do  not  expect  him  to  froth  and  fume  when  he  hears 
of  it.  He  will  probably  not  say  a  word,  but  quietly 
look  for  some  one  else  to  whom  he  will  send  chance 
calls,  etc. 

The  people  will  almost  invariably  ask  you  to 
take  charge  of  the  case.  This  you  will  firmly  re- 
fuse in  every  case.  Be  very  careful  never  to  treat  at 
any  future  time  a  case  you  have  looked  after  for 
your  colleague.  He  may  possibly  give  a  forced  con- 
sent, but  he  will  seldom  like  it.  In  the  future  he  will 
be  careful  not  to  send  for  you  on  a  like  service. 
Some  principals  get  over  this  stumbling  block  by  an 


184    BUILDING  A  PROFITABLE  PRACTICE 

arrangement  whereby  the  assistant  pays  50  per  cent, 
of  his  collections  from  such  a  case  accruing  within 
the  next  six  months  or  a  year. 

You  may  feel  piqued  at  the  title  of  assistant; 
sometimes  this  may  be  obviated  by  his  terming  you 
his  colleague,  or  associate.  The  people  will,  how- 
ever, generally  term  you  the  assistant.  Don't  let 
it  bother  you. 

REFERENCES. 

"Saundby  Medical   Ethics,"   J.   B.   Lippincott   &,  Co. 
"Moral  Philosophy  of  Medicine,"  J.  W,  Gouley,  Rebman  &  Co. 
"Medical  Ethics  and  Etiquette,"  Austin  Flint,  Appleton  &,  Co. 
"  Code  of  Ethics  of  the  American  Medical  Association." 
"  Book  on  the  Physician   Himself,"   F.   A.   Davis   Co. 


CHAPTER  XVIII. 
Advertising,  Etc. 

You  are  not  permitted  to  advertise.  The  reason 
for  this  is  quite  plain.  A  layman  is  not  in  a  posi- 
tion to  dispute  the  claims  of  the  advertiser,  what- 
ever they  may  be.  He  is  in  a  position  to  judge  of 
other  goods  by  comparison,  but  for  the  kind  you  have 
to  offer  there  is  no  basis  for  comparison.  The  one 
who  could  write  the  best  ads.  would  have  all  of  the 
practice.  For  this  reason,  the  learned  professions 
have  always  avoided  advertisements.  Lawyers  don't 
advertise  that  they  can  secure  verdicts  in  all  cases. 

These  traditions,  that  have  been  handed  down 
for  ages,  must  be  maintained.  The  essence  of  med- 
icine demands  it,  and  he  who  runs  counter  to  it 
must  bear  with  the  ostracism  that  results.  It  is  ever 
to  the  glory  of  the  profession  that  no  really  skillful 
physician  has  resorted  to  these  methods.  There 
comes  a  time  in  the  life  of  many  physicians  when 
they  feel  that  they  would  like  to  enter  the  adver- 
tising field,  but  either  through  lack  of  confidence  in 
themselves  or  fear  of  being  called  a  quack  by  their 
brother  physicians,  they  confine  themselves  to  the- 
code  of  ethics,  and  it  is  well  that  they  do  so.  All  of 
the  advertising  business  is  not  gold,  and  for  one  who 
does  make  a  little  money,  hundreds  fail  absolutely. 
Practically  all  of  the  most  successful  advertisers  will 

189 


186    BUILDING  A  PROFITABLE  PRACTICE 

tell  you  confidentially  that  if  they  had  their  lives  to 
live  over  again  they  would  prefer  the  general  prac- 
tice of  medicine  wherein  they  could  enjoy  the  con- 
fidence, esteem  and  respect  of  their  patients,  which  is 
never  accorded  to  the  advertiser.  The  laity  invariably 
regard  the  advertiser  as  one  who  is  out  to  do  them  as 
much  as  he  can,  and  hate  the  sight  of  him  as  soon 
as  they  are  cured,  or  he  has  their  money.  Some  few 
may  be  grateful,  but  there  is  never  the  respect  for 
him  that  is  accorded  the  humblest  practitioner.  The 
only  legitimate  form  of  advertising  is  by  showing 
members  of  your  own  profession  what  you  can  do. 
You  do  this  by  sending  them  notices  of  your  opera- 
tions, with  invitation  to  watch  your  work,  by  pre- 
senting cases  and  papers  at  medical  societies,  by 
articles  in  the  medical  press,  and  by  sending  them 
individually  reprints  or  copies  of  such  articles. 
Needless  to  say,  to  none  of  these  fields  should  the 
laity  be  admitted ;  the  layman  cannot  judge  whether 
you  are  talking  sense  or  nonsense.  For  the  same 
reason,  reprints  should  not  be  distributed  among 
laymen,  with  the  possible  exception  of  near  friends 
and  relatives.  Any  other  form  of  advertisement 
must  come  from  the  layman,  praising  your  work  as 
it  affected  him. 

Don't  put  a  card  in  church  bulletins,  programs, 
etc.  Laymen  will  often  solicit  you  to  do  this.  Like- 
wise, it  is  not  good  taste  to  insert  your  honorary 
positions,  etc.,  in  the  telephone  directory. 

Have  plenty  of  your  cards  always  ready  and 
give  them  to  your  friends  and  patients.    The  sight 


ADVERTISING,  ETC.  187 

of  your  card  on  the  mantel-piece  of  the  home  will 
often  remind  them  of  the  fact  that  they  should  con- 
sult the  doctor. 

In  some  of  the  small  towns  it  is  common  practice 
to  insert  a  card  in  the  local  paper  with  address  and 
oflfice  hours.  There  is  nothing  ethically  wrong  in 
this;  also,  if  you  have  been  away  for  a  long  period 
it  is  customary  to  insert  a  card,  informing  your  pa- 
tients that  you  have  returned  to  practice.  This  is 
more  commonly  made  gratis  as  a  reading  notice  by 
the  news  reporter.  In  the  large  cities  the  prominent 
Italian  physicians,  following  the  custom  of  their 
native  land,  insert  professional  cards  in  the  daily 
press.  The  lesser  fry  have  some  additional  mat- 
ter, specifying  their  specialty,  etc.  Thus  far  this 
contagion  has  not  affected  other  races. 

Beware  of  making  close  friendship  with  re- 
porters of  the  daily  press.  Their  enthusiasm  is  apt 
to  bring  you  discredit  among  the  profession.  I 
have  known  physicians  who  have  ridden  into  good 
practice  through  the  energy  and  boasting  of  their 
wives.  That  is  a  field  of  advertisement  that  is,  of 
course,  uncontrollable.  Your  wife  can  make  herself 
prominent  in  local  circles,  and  by  using  tact  and 
diplomacy  manage  to  bring  her  husband  into  the 
limelight.  Many  women,  particularly  neurasthenics, 
have  a  bundle  of  trouble  they  desire  to  open  and  dis- 
play to  their  envious  friends,  and  this  affords  a  good 
opportunity  for  the  doctor's  wife  to  make  a  dem- 
onstration of  sympathy  and  relate  how  successful 
he  is  in  such  cases.    If  you  have  your  name  on  diet 


188    BUILDING  A  PROFITABLE  PRACTICE 

slips,  on  your  dispensing  envelopes,  etc.,  it  is  in  a 
sense  advertisement,  and  a  legitimate  form  of  ad- 
vertising at  that. 

BOASTING  ABOUT  CASES. 

It  is  perfectly  natural  that  you  should  feel  proud 
of  your  successful  cases,  and  it  is  just  as  natural 
that  you  sing  your  own  praises.  The  most  valuable 
compensation  from  such  cases  is  the  satisfaction  of 
work  well  done.  Your  boasting,  provided  it  is  done 
in  a  dignified  manner,  will  help  you,  but  be  careful 
not  to  offend  anyone.  Anyone  who  asserts  his 
prowess  will  be  believed  by  the  majority.  In  after 
years  you  will  probably  smile  at  the  assertiveness 
of  your  early  years ;  nevertheless,  it  will  do  you  no 
harm. 


CHAPTER  XIX. 

Commissions. 

Within  recent  years  the  commission  evil  has 
sprung  up  among  some  of  the  older  men.    This  is 
one  of  the  gravest  crimes  against  the  code  of  ethics. 
It  will  blast  a  young  man's  reputation,  as  it  will 
invariably  be  found  out.    To  an  older  man  it  is  not 
so  harmful  as  far  as  reputation  and  practice  goes, 
yet  it  demoralizes  and  debauches  him.    Under  no  cir- 
cumstances can  you  honestly  accept  commissions 
from  consulting  physicians,  surgeons  or  specialists. 
If  you  call  a  surgeon  in  to  operate  on  a  patient,  it 
is  only  just  that  you  should  be  asked  to  assist  at  the 
operation.    You  can,  with  very,  very  rare  exceptions, 
do  this  as  well  as  his  first  assistant,  and  for  this 
the  surgeon  should  compensate  you  as  liberally  as 
he  would  his  regular  first  assistant,  provided  you  do 
not  wish  to  charge  the  family  directly  for   such 
service.    As  stated  before,  the  first  assistant's  fee 
for  a  major  operation  varies  from  $10  to  $100,  de- 
pending on  the  amount  of  service  rendered  and  the 
circumstances  of  the  patient.    It  is  well  to  have  an 
understanding  with  the  surgeon  in  this  matter  be- 
fore the  bills  are  sent  in.    It  is  customary  for  the 
surgeon  to  send  a  bill  covering  the  operation,  as- 
sistance, etc.    If  possible,  you  should  have  the  after- 
treatment  of  surgical  cases,  for  which  you  will  be 

180 


190    BUILDING  A  PROFITABLE  PRACTICE 

paid  by  the  patient  unless  the  surgeon  wishes  to 
compensate  you. 

People  will  often  wish  you  to  take  them  to  the 
specialist.  For  this  you  should  be  compensated  by 
them.  If  you  assist  at  any  office  work  or  operation, 
the  consultant  may  pay  you  for  the  service,  as  he 
would  a  nurse  or  other  doctor. 

Sometimes  you  will  be  asked  by  the  patient  to 
be  present  at  a  hospital  operation.  Your  advice 
under  such  circumstances  may  be  of  great  value  to 
the  operator  and  patient.  In  such  a  case,  intimate 
that  it  will  cost  him  something.  Say,  *'If  you  wish 
me  to  go — of  course  I  will,  but  it  will  take  a  good 
deal  of  time  on  my  part,''  putting  the  time  and  date 
in  your  memorandum  book  while  talking  to  him.  If 
the  attending  surgeon  wishes  your  advice  during 
convalescence  and  asks  you  to  call  he  should  com- 
pensate you  for  it.  If  a  patient  asks  you  to  call  and 
see  him  at  the  hospital  he  should  pay  you  for  such 
services,  even  though  you  are  not  connected  with 
the  hospital.  Personally,  in  several  instances  we 
have  been  able  to  suggest  changes  in  operation,  fur- 
ther explanations,  etc.,  during  such  operations  that 
made  the  operation  a  success,  where  otherwise  it 
would  not  have  been.  This  was  possible,  because  of 
a  more  intimate  knowledge  of  the  patient.  It  is  but 
just  that  you  should  be  compensated  in  such  cases 
for  your  time  and  advice,  either  by  the  attending 
surgeon  or  by  the  family.  You  can  explain  this  to 
the  patient  beforehand. 

Many  surgical  instrument  houses  make  it  a  rule 


COMMISSIONS  191 

to  send  a  check  for  a  percentage  of  the  price  re- 
ceived from  patients  sent  to  them  for  glasses,  band- 
ages, trusses,  etc.  This  custom  has  become  well- 
nigh  universal ;  the  patient  is  not  charged  more  than 
the  catalogue  prices  and  possibly  receives  more  at- 
tention by  virtue  of  the  fact  that  he  comes  recom- 
mended by  a  physician  than  if  he  comes  otherwise. 
Certainly,  no  injustice  is  done  the  patient.  Few  men 
will  go  to  the  trouble  to  return  such  small  sums. 
Strictly  speaking,  this  should,  however,  be  done. 
One  way  out  of  the  dilemma  is  to  turn  such  money 
over  to  any  charity  in  which  you  are  interested; 
otherwise,  return  the  money  to  the  patient.  If  you 
choose  to  fit  the  patient  with  these  appliances  your- 
self you  may  buy  them.  Charge  a  fair  fee  for  your 
trouble. 

Within  the  last  few  years  a  number  of  proprie- 
tary concerns  have  sent  agents  among  physicians, 
offering  them  stock  bonuses,  commissions,  etc.,  if  they 
will  consent  to  prescribe  their  nostrums.  These 
transactions  are  all  of  them  essentially  wrong,  be- 
cause they  interpose  an  object  between  the  doctor 
and  the  patient  beyond  that  of  the  patient's  interest 
and  advantage.  The  patient  trusts  you  implicitly 
and  any  breach  of  confidence  is  infamous.  It  is  al- 
ways found  out,  because  the  druggist  takes  pains 
to  circulate  the  fact  among  his  customers  and 
among  the  neighboring  physicians. 

It  is  ethically  wrong  to  give  testimonials  for  any 
secret  nostrum.  Avoid  giving  laudatory  notices  to 
proprietary  articles  and  food,   etc.     This  is  not 


192    BUILDING  A  PROFITABLE  PRACTICE 

strictly  unethical,  but  it  is  dangerous  ground.  The 
vendors  of  these  drugs  generally  seek  such  notices 
from  beginners. 

PATENTS  AND  PEOPRIETABIES. 

The  code  of  ethics  strictly  forbids  your  giving  any 
recommendation  for  any  proprietary  medicine  or 
patent  mixture,  etc.  Sedulously  avoid  it,  as  in  later 
years  it  may  be  brought  out  against  you.  Like- 
wise, you  cannot  get  any  patents  for  surgical  im- 
plements nor  patent  medicines,  etc.  You  may  from 
time  to  time  hear  of  the  wonderful  success  of  some 
advertised  secret  remedy,  and  it  may  make  you 
partly  believe  in  its  value;  but  remember  that  the 
most  famous  supposed  specifics  often  contain  sugar 
water,  and  a  coloring  and  flavoring  mixture  as 
viewed  in  the  light  of  pharmacologic  examination. 
Fortunately  the  tricks  of  medicine  will  out,  and 
there  is  hardly  a  secret  in  the  practice  of  medicine 
to-day  which  cannot  be  exposed  and  duplicated  with 
equal  therapeutic  effect. 


CHAPTER  XX. 

Consultation  and  Consultant. 

Aftek  a  patient  has  called  several  times  and  is 
discontented  over  the  fact  that  he  is  not  improving, 
you  may,  if  he  is  a  good  patient,  suggest  a  consulta- 
tion. In  any  event,  if  you  do  not  understand  the 
disease,  or  if  some  serious  affection  of  one  of  the 
special  senses  is  present,  you  should  suggest  a  con- 
sultation. Always  impress  upon  the  patient  that 
you  treat  all  ordinary  diseases  of  all  organs,  but 
that  this  is  an  extraordinary  case.  Unless  he  has 
suggested  some  one  else,  send  him  to  a  specialist 
that  you  know  to  be  honorable  and  experienced.  It 
is  a  good  policy  to  take  the  patient  to  the  doctor's 
consulting  room  yourself,  having  notified  him  be- 
forehand of  your  coming.  In  this  way  you  will  have 
become  familiar  with  his  methods  of  examination 
and  treatment.  You  should  do  this  in  all  cases,  if 
you  do  not  know  the  consultant  to  be  absolutely 
honest.  For  this  reason  a  personal  acquaintance 
with  specialists  is  of  great  value  to  yourself.  If 
you  send  a  letter  with  the  patient,  be  sure  that  there 
is  nothing  in  the  letter  that  you  would  not  trust  the 
patient  to  read,  as  in  many  instances  it  will  be 
opened. 

In  this  letter  you  may  mention  the  financial  con- 
dition of  the  patient,  if  you  think  that  he  is  unable 

13  19S 


194    BUILDING  A  PROFITABLE  PRACTICE 

to  pay  the  specialist's  regular  fee,  sometimes  even 
stating  how  much  you  think  he  can  afford.  Some 
men,  instead  of  stating  the  fee  that  they  think  the 
patient  can  afford,  use  a  code  word  containing  ten 
letters,  suck  as  Galveston.  If  the  patient  can  pay 
only  two  dollars  then  an  A  is  placed  prominently 
in  the  letter. 

Instruct  the  consultant  that  you  yourself  wish  to 
treat  the  patient  according  to  his  directions,  unless 
it  be  an  operation  case.  If  you  do  not  do  this  he 
may  continue  treating  the  case,  doing  things  you 
could  do  just  as  well,  and  meanwhile  you  are  losing 
the  accompanying  fees.  Of  course,  if  you  could  not 
give  the  treatment  you  have  no  rights  in  the  mat- 
ter. Some  patients  will  pay  you  for  your  time  in 
going  to  the  consultants  with  them,  others  will  not. 

In  order  to  succeed  in  the  profession,  we  must 
first  be  honest  in  every  sense  of  the  word.  Remem- 
ber, you  are  dealing  with  the  most  precious  thing  in 
human  life — life  itself.  If  you  do  not  know  any- 
thing about  a  serious  case,  call  some  one  who  does 
know.  It  is  even  better  to  be  called  a  fool  than  to 
sacrifice  a  human  life.  Your  name  should  be  a  syn- 
onym for  honesty,  and  your  word  should  be  as  good 
as  your  bond.  People  generally  take  it  for  granted 
that  you  are  honest  and  for  the  most  part  do  not 
suspect  you  of  unworthy  motives.  Therefore,  in 
any  case  in  which  there  is  any  serious  doubt  in  your 
mind  as  to  whether  you  are  treating  a  case  properly 
or  not,  don't  hesitate  to  ask  for  a  consultation.  If 
a  different  mode  of  treatment  is  likely  to  cure  a 


CONSULTATION  AND  CONSULTANT   195 

patient,  you  must  secure  it  for  him.  The  cases 
wherein  you  will  make  this  error  are  few  and  far 
between;  so  do  not  be  in  a  hurry  to  call  counsel  at 
the  least  change  for  the  worse.  On  the  other  hand, 
in  case  the  patient  is  a  prominent  personage  and  is 
seriously  ill,  it  is  often  wise  to  have  some  one  else 
share  the  responsibility  by  giving  his  counsel  quite 
early  in  the  case.  Always  ask  for  a  consultation  in 
any  severe  abdominal  condition  or  as  soon  as  you 
have  made  a  diagnosis  of  appendicitis,  obstruction 
of  the  bowels,  fracture  of  the  skull,  or  a  membranous 
croup  that  does  not  improve.  Generally  it  will  be 
the  friends  of  the  patient  who  will  wish  the  consul- 
tation. When  you  feel  this  in  the  air,  when  the 
people  say,  ''Doctor,  are  you  quite  sure  of  so  and  so 
being  the  case,"  etc.,  forestall  their  demand  by  say- 
ing that  you  would  be  glad  to  have  some  one  else  see 
the  case  with  you  in  consultation.  They  will  natu- 
rally say,  "Well,  whom  would  you  like?"  It  is  well 
to  appear  broad-minded  and  announce  that  you 
would  be  glad  to  meet  anyone  whom  they  would 
choose,  at  the  same  time  suggesting  some  one  whom 
you  know  to  be  honest  and  experienced.  The  family 
will  often  wish  their  old  family  physician,  in  which 
case  you  must  acquiesce.  Certainly  do  so  if  he  is  a 
man  of  standing  and  good  reputation.  These  facts 
you  can  find  out  by  looking  over  his  society  mem- 
bership in  any  medical  directory.  If  you  have  good 
reason  to  suspect  him  and  his  motives,  you  can  say, 
"As  long  as  we  are  going  to  the  expense,  why  not 
get  a  prominent  man,  a  specialist  or  prominent 


196    BUILDING  A  PROFITABLE  PRACTICE 

teacher  from  the  city?*'  This  will  usually  appeal  to 
them.  Nowadays  it  is  seldom  that  there  is  much 
trouble  in  consultations.  If  a  homoeopath  or  elec- 
tic  be  selected,  consult  with  him  and  you  will  find 
that  there  will  be  very  little  disagreement  in  diag- 
nosis and  treatment.  You  may  give  his  potencies 
with  your  own  medicines.  You  will  arrange  with 
the  consultant  as  to  the  time  of  consultation.  It  is 
customary  that  you  should  get  to  the  house  before 
the  consultant.  Go  over  the  case  again,  carefully 
examining  the  patient  before  the  consultant  arrives. 
Do  this  lest  a  new  complication  or  some  hidden 
symptom  has  become  suddenly  apparent,  much  to 
your  discomfiture  when  found  by  the  consultant. 
Explain  to  the  people  that  he  should  be  paid  then 
and  there. 

THE    CONSULTATION. 

In  arranging  for  a  consultation  you  should  make 
the  appointment,  although  at  times  the  laity  will 
take  it  on  themselves  to  do  so.  It  is  nice  etiquette 
for  the  consultant,  chosen  by  them,  to  suggest  that 
you  be  instructed  to  open  the  communication  with 
him.  This  is  not  absolutely  necessary,  but  it  makes 
for  a  better  feeling.  How  long  should  one  wait  for 
a  consultant  or  attending  physician?  Unless  some- 
thing is  known  as  to  the  cause  of  delay,  not  more 
than  one-half  hour  should  be  thus  wasted.  In  such 
a  case  the  next  consultation  should  be  arranged  for 
by  leaving  a  note  to  that  effect,  or  permission  given 
to  the  consultant,  should  he  arrive  later,  to  ex- 


CONSULTATION  AND  CONSULTANT   197 

amine  the  patient  and  to  refrain  from  discussion 
before  the  friends  or  patient,  and  to  forward  instead 
a  written  statement  to  them,  after  he  had  discussed 
the  case  with  you.  Such  a  procedure  is  rarely  fol- 
lowed, and  everything  should  be  sacrificed  by  both 
parties  to  be  prompt  at  such  meetings. 

After  the  consultant  has  entered  and  mutual 
greetings  are  exchanged,  you  and  he  will  go  into 
another  room;  you  then  inform  him  of  the  details 
of  the  case.  In  entering  the  sick-room,  the  attending 
physician  should  have  precedence.  He  should  then 
introduce  the  consultant,  and  if  he  does  not  care 
to  examine  the  case  again,  turn  the  patient  over 
to  the  consultant.  After  a  very  thorough  examina- 
tion— and  the  attending  physician  should  see  to  it 
that  he  makes  a  thorough  examination,  if  he  has 
asked  for  the  consultation — both  should  retire.  The 
consultant  should  not  make  any  unnecessary  re- 
marks as  to  the  disease,  etiology,  etc.,  or  hint  at 
the  errors  of  the  attendant  before  the  patient. 
After  adjourning  to  the  room  chosen  for  the  con- 
sultation, the  consultant  should  ask  the  friends  to 
withdraw.  This  saves  the  attending  physician  need- 
less embarrassment.  Then  the  door  should  be  care- 
fully closed.  Eaves-dropping  is  very  common,  and 
a  sudden  opening  of  the  door  will  often  be  followed 
by  rustling  of  skirts  and  slamming  of  the  doors. 
High  tones,  whether  in  joking  or  otherwise,  are  al- 
most always  taken  to  mean  that  the  consultant  is 
scolding  you.  For  this  reason  a  subdued  tone  should 
be  employed  in  conversation.  Every  word  and  move- 


198    BUILDING  A  PROFITABLE  PRACTICE 

ment  between  you  two  will  be  watched  until  the 
consultant  leaves  the  neighborhood.  The  consulta- 
tion should  not  be  too  long,  as  the  patient  or  his 
friends  are  apt  to  think  that  there  is  something  very 
wrong  with  the  case,  or  some  lack  of  agreement. 
After  you  have  agreed  in  the  diagnosis  and  treat- 
ment, the  attending  physician  writes  any  prescrip- 
tion necessary,  at  the  dictation  of  the  consultant. 
Then,  if  the  case  be  a  serious  one  and  the  outlook 
gloomy,  the  friends  should  be  called  into  the  room, 
and  much  diplomacy  is  needed  in  not  alarming  the 
patient  by  sudden  withdrawal  of  the  friends  and  by 
their  reappearance  with  weeping  eyes,  etc.  If  the 
outlook,  on  the  other  hand,  be  good,  the  consultant 
and  yourself  may  come  into  the  room  with  the  pa- 
tient and  friends  at  once.  In  any  event,  he  should 
come  into  the  presence  of  the  patient  before  he 
leaves  the  house  and  make  the  patient  as  comfort- 
able, mentally,  as  possible.  The  consultant  will  in 
presence  of  those  responsible  for  calling  him  outline 
the  etiology,  diagnosis  and  prognosis,  and  the  bur- 
den is  then  on  him.  G-enerally  speaking,  the  more 
gloomy  the  prognostications  are,  the  easier  it  is  for 
you. 

If  there  has  been  any  change  in  treatment,  it  is 
seldom  necessary  that  the  medicines  be  changed  at 
once  unless  it  be  of  great  import ;  it  is  better  to  re- 
frain from  ordering  the  new  mixture  for  a  day  or 
two.  In  this  way  the  miraculous  change  that  some- 
times follows  a  consultation — at  least  in  the  eyes  of 
the  laity — ^will  not  be  credited  to  the  new  medicine 


CONSULTATION  AND  CONSULTANT      199 

which,  in  their  minds,  the  family  doctor  should  have 
prescribed  long  ago. 

Treat  a  consultation  as  a  serious  matter;  it  is  a 
very  serious  matter  to  the  patient.  In  many  cases 
it  is  to  him  the  same  ordeal  that  a  prisoner  goes 
through  when  the  jury  retires  to  render  a  verdict. 
So  do  not  joke  with  the  consultant,  and  he  should 
not  do  so  with  you.  This  is  especially  so  when  you  are 
discussing  the  case  in  the  ante-room.  The  patient 
and  friends  expect  that  your  entire  conversation 
shall  be  on  this  particular  case,  and  they  have  a  per- 
fect right  to  the  entire  time  and  attention  of  both 
of  you,  because  they  are  paying  for  it.  Don't  let 
the  consultant  wander  off,  but  keep  the  conversation 
on  the  particular  case  in  hand. 

It  is  the  consultant's  duty  to  uphold  you  before 
the  patient,  unless  you  have  been  grossly  negligent. 
He  cannot  be  in  a  position  to  properly  judge  your 
past  treatment,  and  should  under  no  circumstances 
criticise  you.  If  there  be  a  disagreement  in  diag- 
nosis, prognosis  or  treatment,  it  should  not  be  em- 
phasized before  the  patient  or  friends.  If  you  are 
absolutely  certain  of  your  ground,  you  may  follow 
your  own  line  of  treatment  in  conjunction  with  his, 
or,  if  necessary,  call  in  another  consultant.  Don't 
appear  to  be  hurt  over  any  change  in  treatment,  and 
don't  throw  up  the  case  as  a  result  of  disagreement. 
No  possible  credit  can  accrue  to  you  as  a  result  of 
such  a  course.  You  may  strut  about  with  a  more  in- 
dependent air,  but  it  will  not  help  you  financially 
or  otherwise. 


200    BUILDING  A  PROFITABLE  PRACTICE 

The  consultant  should  not  answer  any  questions 
unless  in  the  presence  of  the  attending  physician. 
When  the  doctors  are  firm  friends,  of  course  this 
rule  does  not  obtain.  While  awaiting  the  arrival  of 
the  attending  physician,  the  consultant  should  in- 
variably refuse  to  hear  a  history  of  the  case  from 
the  patient  or  friends. 

Sometimes  the  consultant  is  asked  to  repeat  the 
consultation  as  a  matter  of  politeness  or  respect. 
It  is  generally  good  form  to  say,  that  he  will  be  glad 
to  come  as  often  as  the  attending  physician  thinks 
necessary.  He  should  never  tell  the  friends  to  let 
him  know  how  the  case  progresses. 

In  some  instances,  if  he  discusses  the  case  with 
the  attending  physician  again  over  the  telephone, 
a  charge  is  made  for  such  advice. 

Sometimes  the  friends  will  go  to  the  consultant 
with  the  story  that  the  attending  physician  does 
not  properly  handle  the  case.  Rarely  this  may  be 
true,  yet  the  consultant  should  never  step  in  in  such 
a  case,  except  in  an  emergency,  and  he  should  not 
suggest  the  name  of  any  other  physician,  unless  there 
be  something  grossly  wrong.  Such  a  procedure  al- 
ways causes  ill-feeling  against  the  consultant. 
Whether  or  not  he  should  consult  on  the  case  with 
another  physician  is  a  nice  point.  Before  doing  so, 
he  ought  to  communicate  with  the  first  attending 
physician.  Sometimes  the  friends  will  call  privately 
on  the  consultant  and  try  to  discuss  the  case  with 
him.  He  should  refuse  to  do  this,  but  if  he  does,  he 
is  in  dnty  bound  to  repeat  all  of  the  nice  things  that 


CONSULTATION  AND  CONSULTANT   201 

he  said  in  your  presence,  and  then  he  ought  to  tele- 
phone you.  In  any  event,  criticism  made  by  him 
then  that  he  did  not  utter  to  the  family  at  the  con- 
sultation is  malicious. 

You  will  often  be  in  doubt  as  to  the  proper  con- 
sultant to  be  called  in,  i.e.,  whether  he  be  a  medical 
or  a  surgical  consultant.  As  a  general  rule,  when 
in  doubt,  the  medical  man  will  have  the  larger  view- 
point, but  in  almost  all  abdominal  disturbances  of 
an  acute  character  the  surgeon  should  be  called  first. 

The  consultant,  aside  from  his  scientific  knowl- 
edge, should  have  three  qualifications,  namely, 

Conscience, 
Modesty,  and 
Professional  honesty 

toward  his  colleague.  He  should  study  the  case 
without  haughtiness  and  without  absolutism.  He 
should  modestly  listen  to  the  views  and  opinion  of 
the  attending  physician;  he  should  avoid  undue 
opinions  which  would  place  the  family  physician  in 
a  difficult  position,  if  the  disease  progresses  badly. 

Anyone  who  sees  a  case  with  you  in  consulta- 
tion should  never  undertake  the  case  at  a  later 
period;  he  ought  not  to  treat  a  case  in  the  same 
family  in  strict  justice.  This  rule  is  not  applicable 
when  the  former  family  physician  is  called  in,  al- 
though he  seldom  will  take  the  case.  The  second 
part  of  this  rule  is  not  applicable  in  small  places, 
because,  if  there  were  a  large  number  of  consulta- 
tions, the  best  practitioner  might  find  himself  en- 


a02    BUILDING  A  PROFITABLE  PRACTICE 

tirely  cut  off  from  the  good  families  of  the  place  in 
which  he  was  called  as  consultant.  It  would,  how- 
ever, be  very  bad  taste  on  his  part  to  treat  a  case 
as  a  general  practitioner  in  that  immediate  family 
within  a  year  or  so.  Certainly  he  should  not  see 
the  patient  professionally  within  that  time. 

The  case  is  somewhat  different  when  the  con- 
sultant is  a  consultant  pure  and  simple,  i.e.,  one  who 
does  not  undertake  outside  practice.  In  such  a  case, 
if  the  patient  calls  on  him,  he  should  notify  you  and 
send  the  patient  back  to  you  as  soon  as  possible.  He 
may  treat  members  of  the  patient's  family  at  his 
office,  provided  they  are  not  under  your  care.  A 
consultant  should  never,  under  any  circumstances, 
take  the  place  of  the  attending  physician  unless  the 
doctor  be  incapacitated,  or  by  special  request  of  the 
attending  physician. 

CONSULTANTS. 

Consultants  may  be  divided  into  three  general 
classes : 

1.  Those  who  limit  themselves  to  office  practice, 
and  who  see  patients  at  their  homes  only  as  a  con- 
sultant. For  this  reason  they  have  no  family  prac- 
tice. They  are  free  to  treat  anyone  who  comes  to 
their  office,  provided  they  have  not  seen  the  patient 
in  consultation  with  another  physician.  They  do  not 
visit  any  patient  except  in  company  with  the  attend- 
ing physician.  There  are  not  many  such  consult- 
ants, and  they  are  to  be  found  only  in  the  large  cities. 
Specialists,  i.e.,  those  limiting  their  practice  to  cer- 


Ideal  exaniining-room  of  a  consultant  gynaecologist. 


CONSULTATION  AND  CONSULTANT   203 

tain  organs,  in  a  measure  follow  the  same  course, 
yet  it  is  not  uncommon  for  tliem  to  see  patients  at 
their  homes,  provided  they  did  not  originally  come 
to  them  through  another  doctor. 

There  is  the  second  class  of  general  consultants, 
who,  while  practising  internal  medicine,  both  at  the 
office  and  at  the  homes  of  their  patients,  do  a  certain 
amount  of  consultation  practice.  This  is  a  midway 
position,  and  such  men  strive  to  limit  themselves 
eventually  to  the  province  of  the  first-named  class. 
There  is  always  some  distrust  of  this  class,  because 
of  the  fact  that  their  reputation  as  a  consultant  may 
give  them  an  imfair  advantage  over  the  practitioner 
when  it  comes  to  his  family  practice.  In  most  cases 
this  distrust  is  unwarranted. 

The  average  fee  is  $10  at  the  office  and  $25  at  the 
house. 

The  third  class  of  consultants  are  the  old  family 
doctors  or  your  colleagues  and  equals  whom  you 
call  in  to  help  you  out  or  to  reassure  the  minds  of 
the  family  and  friends  of  the  patient.  The  average 
fee  for  the  third  class  is  from  $5  to  $10  for  a  con- 
sultation. 

"Whenever  a  patient  under  your  care  calls  at  the 
office  of  a  specialist  or  consultant,  the  specialist 
should  notify  you  at  once,  explaining  the  case  and 
the  nature  thereof.  He  should  do  this  whether  you 
send  the  patient  there  or  whether  he  goes  inde- 
pendently. Eye  specialists  are  not  so  prompt  in 
this  matter  and  often  treat  members  of  the  family 


204    BUILDING  A  PROFITABLE  PRACTICE 

for  glasses  without  notifying  the  practitioner.    In 
such  cases  the  omission  is  excusable. 

To  those  of  you  who  aim  to  become  consultants, 
several  avenues  are  open: 

1.  To  climb  the  ladder  through  clinical  experi- 
ence, gained  in  general  practice. 

2.  To  lay  such  a  complete  foundation  as  a  path- 
ologist that  the  transition  is  easy. 

3.  To  devote  your  time  entirely  in  hospitals  and 
dispensaries  and  laboratories,  content  to  wait  for 
years  before  you  can  make  a  living. 

In  former  years  the  first  avenue  was  the  only 
way.  To-day,  many  of  our  leading  consultants  have 
arrived  by  either  of  the  latter  roads.  The  way  is 
long  and  the  goal  uncertain;  but  it  pays  well  when 
success  is  assured. 

In  all  professions,  the  higher  up  the  ladder  one 
climbs,  the  less  the  competition,  and  there  is  always 
room  at  the  top,  no  matter  how  crowded  the  profes- 
sion is  in  the  main.  In  either  case,  your  entrance 
to  the  medical  profession  will  be  by  contributions  to 
medical  literature  and  medical  societies.  This  will 
allow  your  brother  practitioners  an  insight  into  the 
sort  of  work  that  you  are  doing,  and  they  will  con- 
sult with  you  as  they  measure  your  ability.  This 
means  from  ten  to  twelve  years  of  labor  before  a 
living  can  be  obtained. 

REFERENCES. 
"Medical  Ethics  and  Etiquette,"  Austin  Flint,  Appleton  &  Co. 


CHAPTER  XXI. 

Certificates. 

The  giving  of  certificates  of  one  form  or  another 
constitutes  an  important  portion  of  one's  daily 
medical  practice. 

HEALTH   CEBTIEICATE. 

The  general  form  of  health  certificates  is  as  fol- 
lows : 

This  is  to  certify  that  John  Jones  has  been  ill  and  under  my 

care  suffering  from which  has 

confined  him  to  bed  for He   has 

been  incapacitated  for  this  period. 

Dr 

In  case  you  have  not  treated  the  patient,  you 
can  give  him  a  statement  to  the  effect  that  Mr.  Jones 
has  recovered  and  is  now  fit  to  go  to  work.  As  most 
of  these  certificates  are  mere  formalities,  which 
serve  to  keep  a  position  open  for  the  bearer,  you 
will  do  well  to  give  them  freely.  In  most  cases,  if 
they  are  given  independent  of  a  call,  you  can  charge 
an  office  fee.  Always  prescribe  something  when  you 
give  one  to  a  person  not  already  under  treatment. 

BIBTH  CERTIFICATES. 

Birth  certificates  must  be  filled  out  as  directed 
by  the  local  board  of  health  within  ten  days  after 
the  birth  of  the  child.  This  is  quite  an  important 
matter,  as  in  most  States  there  are  laws  regulating 

ao5 


206    BUILDING  A  PROFITABLE  PRACTICE 

the  age  at  which  children  may  enter  school  and  at 
what  age  they  may  go  to  work.  Such  age  statement 
must  be  accompanied  by. a  copy  of  the  birth  cer- 
tificate. 

DEATH   CERTIFICATES. 

Still-birth  certificates  are  given  in  lieu  of  death 
certificates  in  case  of  death  before  delivery.  Among 
the  poor,  if  the  child  lives  only  a  few  minutes,  it  is 
the  custom  of  many  practitioners  to  give  a  still- 
birth certificate,  because  the  cost  of  burial  under 
such  circumstances  is  much  less  than  if  a  regular 
death  certificate  is  filed.  This  is  not  altogether 
legal.  Death  certificates  are  given  in  all  cases  of 
death.  In  most  cities  you  must  be  a  registered  phy- 
sician and  have  been  in  attendance  on  the  deceased 
at  least  twenty-four  hours  before  death.  Practically 
this  rule  is  not  enforced,  if  you  are  absolutely  cer- 
tain of  the  cause  of  death.  In  any  case  you  must  see 
the  patient  at  least  once,  and  some  hours  before 
death.  If  you  are  called  in  and  find  a  patient  dead, 
who  has  been  suffering  from  a  chronic  disease  and 
imder  your  care,  you  may  sign  the  certificate,  even 
though  you  did  not  see  the  patient  for  weeks  before 
death.  However,  you  should  instruct  the  families  of 
such  incurable  cases  to  notify  you  when  death  is  ap- 
proaching, so  that  you  can  satisfy  the  law.  When  you 
are  called  in  to  see  a  dead  stranger  or  one  not  under 
your  treatment,  you  must  notify  the  coroner's  office 
at  once.  If  you  are  positive  that  death  has  been 
due  to  natural  causes,  leave  a  note,  explaining  the 


CERTIFICATES  207 

case  to  the  coroner.  Coroner's  autopsies  are  sel- 
dom held  unless  there  is  some  good  reason.  Don't 
get  into  trouble  with  the  coroner,  as  it  will  cause 
unfavorable  newspaper  notoriety,  to  say  the  least. 
In  large  cities  death  due  to  certain  causes,  as  ery- 
sipelas, contagious  diseases,  abortion,  etc.,  must  be 
explained  before  the  certificate  is  passed  by  the 
health  department.    Avoid  ambiguous  terms. 

The  nomenclature  as  to  cause  of  death,  as  de- 
vised by  the  board  of  Bellevue  and  allied  hospitals, 
is  now  taken  as  a  standard  throughout  the  country. 
As  pneumonia  is  so  commonly  present  as  a  terminal 
infection,  you  can  give  it  as  cause  of  death,  when  you 
are  in  doubt  as  to  the  exact  condition.  Heart  fail- 
ure, old  age  and  the  like  are  no  longer  accepted  as 
causes  of  death.  In  certifying  as  to  age,  inquire  if 
there  is  any  insurance,  and  unless  there  be  appar- 
ent some  wide  divergence  between  the  given  age  and 
the  age  on  the  policy,  fix:  the  age  according  to  the 
statements  given  in  the  insurance  application,  as  a 
disparity  between  these  two  is  often  the  cause  of 
much  trouble  in  collecting  the  insurance. 

INSURANCE   CERTIFICATES. 

Insurance  certificates  are  of  two  kinds:  (1)  acci- 
dent, and  (2)  death  insurance.  Accident  insurance 
certificates  are  filled  out  in  a  liberal  manner  without 
any  charge,  providing  the  patient  is  under  your  care. 
Death  insurance  certificates  are  generally  filled  out 
without  charge.  If  the  sum  is  a  thousand  dollars 
or  more,  and  if  you  are  required  to  take  an  affidavit, 


208    BUILDING  A  PROFITABLE  PRACTICE 

you  should  be  compensated  as  for  an  office  visit. 
In  general  it  is  better  to  forego  the  charge  and  have 
the  good  will  of  the  relatives. 

Don't  charge  for  vaccination  certificates  when 
you  have  vaccinated  the  child;  where  you  have  not 
vaccinated  the  child,  then  you  should  charge  an  office 
fee. 

EEPOETING  CONTAGIOUS  DISEASES. 

In  all  the  large  cities  there  are  laws  requiring 
the  reporting  of  contagious  diseases  as  they  occur 
in  your  practice.  You  are  not  compelled  to  report 
them  unless  they  apply  to  you  for  treatment.  Al- 
ways comply  with  this  law.  Under  no  circumstances 
should  you  conceal  any  serious  contagion.  If  you 
do,  and  anyone  loses  his  life  through  your  negligence, 
you  are  morally  guilty  even  though  the  law  does  not 
hold  you  responsible.  People  will  often  importune 
you  to  refrain  from  reporting  such  diseases  with  all 
kinds  of  reasons:  that  their  business  will  be  de- 
stroyed; that  they  will  lose  their  position,  their 
graduation,  etc.  Remember,  that  the  same  people, 
whether  they  are  saints  or  sinners,  will  be  the  first 
to  tell  their  friends  what  you  have  done,  and  these 
will  all  expect  like  treatment.  They  will  tell  you 
that  Dr.  So-and-So,  your  rival,  does  not  notify  the 
authorities  (this  may  be  the  truth,  but  it  is  more 
likely  a  lie).  They  do  this  with  the  object  of  work- 
ing on  your  jealousy  and  for  this,  if  for  no  other 
reason,  be  firm.  Their  protestation  as  to  the  care 
they  will  exercise  has  nothing  to  do  with  the  law. 


CERTIFICATES  209 

Explain  to  them  that  the  law  may  be  so  severe  with 
you  as  to  cause  the  forfeiture  of  your  license.  Also 
point  out  the  injustice  to  others. 

If  through  negligence  you  fail  to  report  a  case 
of  this  kind  and  the  child  dies  you  will  probably 
receive  a  note  from  the  Health  Department  asking 
for  an  explanation.  In  some  cases  severe  fines  are 
imposed.  In  case  of  concealing  wilfully  smallpox 
a  fine  of  $250  may  be  imposed.  If  no  diagnosis  has 
been  made,  of  course  no  charge  can  be  made  against 
you. 


14 


CHAPTER  XXII. 

Prognosis. 

If  possible  avoid  the  giving  of  a  prognosis,  as  it  is 
the  most  diflScult  part  of  medicine.  Always  make  one, 
however,  in  your  own  mind,  as  it  will  be  of  splendid 
training  for  your  future  work.  You  can  often  pre- 
vent questions  as  to  prognosis  by  having  ready,  as 
soon  as  your  examination  is  finished,  such  questions 
as  minute  inquiries  as  to  bowels  and  urine,  or  some 
other  similar  questions,  so  as  not  to  allow  the  pa- 
tient or  his  friends  a  moment  to  quiz  you.  Then 
you  can  get  up  and  get  out  before  anyone  has  a 
chance  to  collect  his  thoughts  to  ask  you  as  to  the 
future.  If  the  ailment  will  require  a  few  weeks  to 
clear  up,  do  not  hesitate  to  say  so,  but  it  is  better  to 
give  more  or  less  indefinite  answers  as  "Quite  some 
time,"  **Much  depends  on  the  vitality'*  or  **on  your 
urine  examination,"  *'Can  tell  better  in  a  few  days," 
and  the  like.  The  question  that  the  people  are 
mostly  concerned  about  is  whether  the  illness  will 
be  fatal  or  not.  If  you  feel  quite  sure  of  his  safety, 
whether  asked  or  not,  do  not  hesitate  to  volunteer  a 
prognosis  as  to  that  feature. 

In  making  prognosis  be  exceedingly  careful;  it 
will  add  much  to  your  reputation  if  it  becomes  well 
known  that,  whenever  you  assure  the  people  of  a 
favorable  ending,  the  patient  and  his  friends  need 
have  no  fear  as  to  the  outcome,  but  that  when  you 

210 


Quick  reference  working  library. 


PROGNOSIS  211 

predict  a  fatal  issue,  it  comes  to  pass  and  nothing 
will  save  him.  This  reputation  can  best  be  secured 
by  the  beginner,  giving  the  fewest  possible  positive 
prognoses.  With  some  of  the  nations  of  North- 
eastern Europe,  a  positive  prognosis  must  always 
be  given  by  those  who  practise  among  them. 

Never  promise  absolute  cure  at  once.  On  the 
other  hand,  never  condemn  any  patient  to  death  un- 
der any  circumstances.  Imagine  yourself  condemned 
to  the  electric  chair ;  the  case  of  telling  a  patient  that 
he  or  she  will  surely  die  of  the  diseases  is  almost  a 
parallel  one.  Don't  say  to  a  patient  ''You  have  an 
incurable  disease."  Pathologically  it  may  be,  yet 
how  many  of  us  have  been  deceived  when  we  judged 
life  from  the  pathologist 's  dictum.  In  extremely  bad 
cases,  or  in  cases  of  progressive  pulmonary  tuber- 
culosis, etc.,  you  can  get  behind  the  delphic  state- 
ment that  you  have  seen  cases  much  worse  recover 
and,  on  the  other  hand,  cases  not  so  bad  pass  away. 
Then  take  care  to  point  out  any  good  features  in 
the  present  case.  Seldom  give  a  gloomy  prognosis, 
because  the  family  will  certainly  get  frightened  and 
will  call  in  their  old  family  physician,  who  will  gen- 
erally reverse  the  prognosis  and  yet  the  patient  may 
succumb  as  you  predicted,  the  family  not  feeling  bit- 
ter toward  the  other  man  because  he  did  not  give 
their  minds  any  anguish.  They  may  be  so  ashamed 
of  themselves  in  doubting  you  that  they  would  rather 
try  another  physician  in  preference  to  yourself.  In 
the  meantime  you  have  lost  the  fees  attendant  on 
the  case.    The  laity  do  not  judge  physicians  by  the 


212    BUILDING  A  PROFITABLE  PRACTICE 

same  standards  that  we  do  and  the  credit  of  an 
accurate  prognosis  is  seldom  appreciated  by  the  laity 
unless  it  be  made  very  striking.  A  wrong  favorable 
prognosis  is  not  so  serious  in  its  consequences,  pro- 
vided you  have  not  made  light  of  the  disease  and 
treated  it  as  though  it  was  a  simple  disorder.  You 
can  always  explain  that  the  disease  took  an  ''unex- 
pectedly bad  turn, "  ' '  one  that  could  not  possibly  be 
foreseen."  People  will  say  that  you  did  not  want 
to  alarm  the  patient,  something  else  happened  to 
bring  it  about,  etc.  Unfortunately,  a  bad  prognosis 
which  turns  out  wrong  makes  one  ridiculous.  We  all 
hear  of  Mr.  X.,  whom  Dr.  S.  or  some  other  great  light 
condemned  to  death  years  ago,  but  who  has  survived 
the  physician  many  years.  The  favorable  prognosis 
has  a  real  therapeutic  value,  and  by  buoying  up  the 
patient  may  actually  help  to  turn  the  tide  in  a  favor- 
able direction;  whereas  the  gloomy  prognosis  will 
either  have  the  reverse  effect  or  send  the  patient 
to  the  quack,  whose  sole  stock  in  trade  is  his  ever 
helpful  promises.  Try  to  cultivate  a  spirit  of  opti- 
mism. You  should  try  to  cultivate  hope  in  your  pa- 
tient; look  on  the  bright  side  of  things.  This  does 
not  mean  that  you  should  not  throw  an  anchor  to 
windward  in  all  doubtful  cases. 

Coleridge  considered  him  the  best  physician  who 
inspired  the  most  hope.  The  hopefulness  and  op- 
timism of  the  physician  do  far  more  than  cure  feeble 
minds  and  faltering  wills.  They  assist  in  the  cure 
in  every  disease  he  encounters.  Elder  Flint  writes, 
**  Undue  solemnity,  anxiety  and  apprehension  in  the 


PROGNOSIS  213 

look,  manner  or  words  of  a  medical  attendant  on  the 
sick  are  extremely  imfortunate;  they  discourage 
patients;  whereas,  on  the  other  hand,  a  cheerful 
mien,  calmness  of  deportment  and  verbal  animation, 
sometimes  accomplish  more  than  drugs." 

Most  people  appreciate  the  fact  that  you  can  tell 
them  what  diseases  they  have  had  without  asking 
the  question.  This  does  not  apply  to  venereal  dis- 
eases that  the  patient  may  have  had.  If  you  see  an 
eye  the  result  of  gonococcus  infection  or  a  syphi- 
litic lesion  anywhere,  do  not  say  anything  as  to  its 
cause  if  you  wish  to  retain  that  person  as  a  patient. 
Of  course,  if  a  patient  bluntly  asks  you  if  he  is  going 
to  get  better  and  you  feel  absolutely  certain  that  he 
will  not,  you  are  in  duty  bound  to  tell  the  truth. 
Honesty  is  always  the  best  policy. 

PROGNOSIS  OF  DEATH. 

One  of  the  most  difficult  parts  of  prognosis  is 
that  relating  to  death  itself. 

If  a  patient  with  hemiplegia  does  not  recover 
consciousness  within  twenty-four  hours,  he  will  die. 
Prolonged  unconsciousness  is  generally  fatal. 

Pulmonary  oedema  in  most  cases  means  death. 

Lobar  pneumonia  with  Bright 's  disease  is  gen- 
erally fatal.  In  fact,  nine-tenths  of  the  pneumonias 
over  sixty  years  of  age  are  fatal. 

If  a  very  sick  patient  in  his  delirium  wants  to  go 
home,  be  prepared  to  give  a  dark  prognosis. 

The  desire  to  move  from  bed  to  bed  is  regarded 
as  bad  luck  by  the  laity  and  is  combated  by  the 


«14    BUILDING  A  PROFITABLE  PRACTICE 

friends.  This  is  doubtless  due  to  the  fact  that  as 
patients  near  death  they  often  wish  to  change  beds. 

When  a  patient  has  lost  one-third  of  his  body 
weight,  he  seldom  recovers. 

In  coma,  death  is  almost  always  preceded  by 
disturbed  respiration  for  a  period  of  several  hours. 
In  coma,  when  the  pulse  remains  the  same  over  a 
long  period,  then  the  respiration,  its  character  and 
frequency,  offers  the  best  means  of  foretelling  the 
outlook  for  the  following  ten  or  twelve  hours. 


CHAPTER  XXIII. 

Diagnosis. 

On  leaving  the  patient's  room  or  house,  you  will 
be  waylaid  by  anxious  friends.  Don't  say  much  to 
any  of  them  who  are  not  members  of  the  family. 
Give  them  indefinite  answers  in  a  cocksure  manner ; 
say  he  is  quite  sick,  quite  bad,  he  is  about  the  same, 
etc.  In  some  cases  you  may  say:  ** Excuse  me,  I 
must  not  talk  of  my  patient's  illness,"  or  in  making 
a  prognosis  to  them  you  can  say  that  nine  out  of 
ten  get  better,  etc.  The  best  way,  however,  is  to  let 
them  do  the  talking  and  for  you  to  shake  your  head 
wisely. 

Never  say  to  a  patient  under  any  possible  cir- 
cumstances: '*I  do  not  know  what  is  the  matter  with 
you,"  or  ''I  don't  know  what  else  to  do."  Imagine, 
if  you  can,  a  pilot  at  sea  who  has  lost  his  course  for 
a  day  or  so,  going  about  among  the  passengers,  say- 
ing, ''I  don't  know  where  we  are."  He  would  be 
considered  a  fool.  Any  sensible  man  would  go  on 
and  say  nothing  for  a  day  or  two,  till  the  storm 
would  clear  up  and  then  he  could  take  his  bearings. 
So  with  your  case.  Let  it  run  along  for  a  day  or  two 
and  the  diagnosis  will  gradually  clear  up.  In  the 
meantime  you  will  have  read  up  everything  possible 
bearing  on  the  subject. 

When  you  have  made  a  diagnosis,  stick  to  it  and 
don't  seem  uncertain  or  wabbling;  don't  mutter  to 
yourself,  ''This  looks  strange"  or  "That  is  queer;" 

fl5 


216    BUILDING  A  PROFITABLE  PRACTICE 

be  always  cocksure  before  the  patient.  With  your- 
self you  can  study  the  case  as  much  as  possible. 
Certain  races  demand  positive  pronouncements  as 
to  disease.  Such  definite  statements  you  know  are 
impossible;  yet  these  people  will  not  be  satisfied 
otherwise.  The  positive  man  will  get  the  practice 
among  them,  and  his  statements  had  better  be  op- 
timistic. 

Above  all,  do  not  talk  much.  More  harm  comes 
from  too  much  talk  than  anything  else.  By  this  I 
do  not  mean  that  you  should  not  explain  things  as 
far  as  possible,  but  it  is  not  possible  for  a  layman 
to  grasp  all  of  the  intricacies  and  inconsistencies  of 
medicine  without  a  foundation  knowledge  such  as 
you  possess.  In  talking  to  patients,  don't  leave  the 
domain  of  medicine ;  that  is  your  own  specialty  and 
stick  to  it.  The  average  physician  becomes  a  fool 
only  when  he  dabbles  in  other  matters. 

If  in  the  course  of  an  examination  you  find  an 
organic  disease  or  abnormality,  you  should  not  con- 
ceal the  diagnosis  unless  the  patient  is  moribund  or 
hopelessly  incurable.  Even  then  such  a  course  is 
questionable;  you  may  perhaps  feel  that  it  is  cruel 
to  tell  the  truth,  but  your  clients  will  seldom  appre- 
ciate your  discretion.  They  come  to  you  as  to  a  me- 
chanic to  find  out  what  is  the  matter  with  them, 
and  they  do  not  expect  that  you  will  deceive  them. 
Ydu  needn't  say  that  it  is  going  to  be  fatal.  In  fact, 
you  must  paint  a  hopeful  picture.  How  can  you  tell 
whether  it  is  not  best  that  the  patient  should  know 
his  true  condition?    No  one  knows  another's  mind 


DIAGNOSIS  217 

so  well  as  to  make  such  a  judgment.  Perhaps  there 
are  many  things  in  his  life  that  would  be  changed 
if  he  knew  of  his  danger.  On  the  other  hand,  the 
tumor,  which  is  not  causing  any  symptoms  and 
which  you  discover  on  a  routine  examination,  may 
not  trouble  the  patient  for  months  or  years,  yet  it 
may  do  so  in  a  few  weeks.  But  when  it  does  cause 
pain  or  mayhap  become  malignant  and  Dr.  So-and- 
So  discovers  it,  you  will  be  blamed  for  not  finding 
it.  Don't  think  to  spare  people  in  such  matters, 
with  the  possible  exception  of  an  inoperable  cancer. 
In  such  a  case  you  must  inform  the  relatives  of  the 
hopelessness  of  the  condition.  Everyone  has  seen 
the  following  occurrence : 

An  old  family  practitioner  who  has  slaved  and 
served  a  family  for  years  finds  an  organic  lesion  in 
one  of  its  members  which  he  believes  will  cause 
needless  worry  if  he  reveals  it.  He  feels  that  he  can 
tide  the  patient  over  the  minor  complaint  and  feels 
strong  in  his  position  as  the  family  adviser.  After 
a  visit  or  two  the  patient  goes  to  another  doctor  who 
discovers  the  lesion  and  gets  all  of  the  credit.  All 
of  the  former  services  of  the  family  doctor  are  for- 
gotten and  the  family  runs  after  the  new  god. 

Announce  all  of  the  abnormalities  found.  If  you 
find  a  heart  murmur  that  is  not  causing  any  trouble, 
explain  that  it  is  not  dangerous  heart  disease.  When 
you  see  enlarged  tonsils,  adenoids,  extensive  pre- 
puce, etc.,  call  the  attention  of  the  patient  or  parents 
to  the  fact.  However,  do  not  insist  on  the  patient 
having  these  things  operated,  unless  it  is  suggested 
by  the  patient  or  parents  themselves. 


CHAPTER  XXIV. 

Ekeobs  in  Peactice. 

If  after  treating  a  case  several  days  or  a  week, 
you  are  certain  that  the  diagnosis  is  erroneous,  be- 
gin to  break  ground  for  a  change  in  diagnosis, 
saying  that  you  believe  something  else  is  developing. 
After  a  few  days  announce  the  new  diagnosis.  You 
will  do  this  to  satisfy  your  own  amour  propre  in 
case  counsel  is  called  as  much  as  any  other  reason. 
Don't  forget  that  any  patient  may  actually  suffer 
from  two  or  more  diseases  at  the  same  time.  At 
all  times  try  to  cultivate  an  inscrutable  face,  so 
that  nothing  surprises  you — the  aequanimitas  of  the 
ancients. 

If  by  any  chance  you  have  made  an  error,  either 
in  diagnosis  or  treatment,  do  not  be  overanxious  to 
admit  it.  Don't  say  anything;  certainly  do  not  vol- 
unteer the  information  that  it  was  your  fault.  You 
are  infallible  to  most  of  your  patients.  You  may 
think  the  people  applaud  your  candor  and  sincerity, 
but  they  will  always  treasure  your  mistakes  up 
against  you.  When  they  become  your  enemies,  you 
will  hear  to  your  mortification  of  how  you  yourself 
admitted  such  and  such  an  error.  Everyone  makes 
errors  and  mistakes,  but  they  don't  tell  the  world 
about  it.  Honesty  and  candor  are  not  synonymous 
terms.  You  should  be  honest,  but  honesty  does  not 
imply  that  you   must  unnecessarily  expose  your 

218 


ERRORS  IN  PRACTICE  219 

weaknesses  to  everyone.  If  a  patient  dies  suddenly 
under  your  care,  or  after  you  have  given  a  new 
medicine  or  performed  an  operation,  go  to  the  house, 
presumably  in  order  to  sign  the  death  certificate, 
and  shape  the  conversation  so  as  to  defend  yourself, 
before  they  have  had  a  chance  to  spread  the  ill 
news.  In  this  way  they  will  not  be  so  ready  to 
accuse  you  when  they  see  that  there  are  two  sides 
to  the  question ;  above  all  things,  do  not  seem  scared 
or  solicitous  over  the  matter.  The  layman  does  not 
view  mistaken  diagnoses  and  treatment  from  the 
same  point  that  we  do.  Often  when  we  think  we 
have  been  very  successful  and  clever  in  our  diag- 
nosis and  treatment,  the  opposite  view  is  held  by 
the  patient  and  his  friends,  and,  on  the  contrary, 
when  we  feel  guilty  of  a  grievous  error  everyone  in 
the  family  lauds  us  to  the  skies. 


CHAPTER  XXV. 

Dispensing. 

The  ideal  method  of  practising  medicine  is  for 
yon  to  write  the  prescription  and  have  it  com- 
pounded by  a  competent  druggist.  In  the  large 
cities,  these  conditions  are  generally  fulfilled.  In 
the  smaller  towns  and  in  some  parts  of  the  large 
cities,  circumstances  are  such  as  to  make  this  ar- 
rangement impossible,  and  the  dispensing  of  tab- 
lets or  liquids  by  physicians  themselves  is  the  rule. 
At  your  first  call  among  your  medical  confreres, 
find  out  if  they  dispense  themselves.  If  they  do  not, 
of  course  you  should  not  be  the  first  to  begin  it. 
If  you  find  that  any  large  percentage  of  them  do 
so,  you  will  be  very  unwise  in  attempting  to  do 
otherwise.  This  is  especially  true  as  far  as  office 
dispensing  is  concerned.  In  places  where  there  is 
any  dispensing  done  unless  there  is  a  druggist  in 
the  immediate  neighborhood  who  is  sending  patients 
steadily  to  you  it  will  be  better  to  dispense  some  of 
your  own  medicines.  In  these  days  of  tablets,  there 
is  little  trouble  in  doing  this.  You  can  buy  enough 
tablets  for  use  during  emergencies  for  $10.  These, 
with  a  thousand  pill  boxes  or  envelopes,  complete 
your  equipment  for  office  dispensing.  Leave  the 
liquid  and  ointment  work  to  the  druggist  unless  you 
are  living  in  the  country  where  there  are  no  drug- 
gists.   No  matter  how  unsatisfactory  your  consul- 

220 


DISPENSING  221 

tation  may  have  been  to  the  patient,  he  goes  away 
with  something  which  may  do  him  good.  He  may 
not  think  your  advice  is  worth  the  cost  of  the  recipe, 
or  he  may  think  he  does  not  need  it;  but  if  he  has 
the  medicine  he  will  take  it,  and  much  more  regu- 
larly in  tablet  than  in  liquid  form,  and  if  any 
good  results  therefrom  you  will  get  the  credit.  Do 
not  think  for  one  moment  that  it  is  only  the  poor 
who  like  to  get  their  medicine  in  this  way;  many 
men  whose  practice  is  almost  solely  among  well-to- 
do  people  dispense  much  of  their  own  medicines. 
The  patient  feels  reasonably  sure  that  the  medicine 
is  certainly  pure  and  that  there  is  no  substitution, 
such  as  is  done  by  many  supposedly  reputable  drug- 
gists. The  public  has  had  its  confidence  in  druggists 
severely  shaken  by  the  phenacetine  exposure  of  a 
few  years  ago,  and  by  the  frequent  investigations 
made  since  then.  Indeed,  the  general  public  knows 
more  about  us  and  our  profession  than  we  believe. 
The  dispensing  of  tablets  enables  one  to  give 
something  for  several  ailments.  At  the  same  time, 
most  patients  come  complaining  of  three  or  four 
distinct  ills — say,  constipation,  indigestion,  muscu- 
lar pains.  Give  such  a  one  three  prescriptions,  and 
he  will  take  the  one  that  looks  the  biggest,  with  pos- 
sible slight  relief  and  you  get  no  credit.  If,  however, 
you  give  him  a  tablet  for  the  constipation,  another 
for  the  indigestion,  and  possibly  a  prescription  for 
the  third  complaint,  you  will  surely  relieve  one  or 
two,  and  possibly  all  of  these  troubles,  and  he  will 
praise  you  correspondingly.    On  the  other  hand,  it 


222    BUILDING  A  PROFITABLE  PRACTICE 

forces  the  patient  to  come  back  to  you  for  the  medi- 
cine, so  that  you  get  the  money  instead  of  the  drug- 
gist. It  also  prevents  him  handing  over  good  pre- 
scriptions to  all  of  his  friends. 

There  are  some  patients  who  are  not  satisfied 
unless  they  receive  liquid  medicine.  Dispensing 
liquids  requires  considerable  labor  on  your  part. 
The  large  pharmaceutical  houses  now  put  your  stock 
prescription  up  in  labeled  bottles  at  an  average 
price  of  10  cents  for  a  two-ounce  bottle.  Some  phy- 
sicians write  out  the  prescription  for  this  and  then 
charge  the  patient  a  sum  averaging  25  cents  for  a 
two-ounce  mixture.  Others  do  not  charge  for  med- 
icine. Of  course,  should  the  patient  at  any  time 
request  the  prescription  for  the  tablets  or  liquid 
that  you  gave  him,  you  should  give  it  to  him.  Often- 
times you  will  get  a  hurry  call  to  go  out  during 
ofiice  hours.  A  few  tablets  given  to  the  messenger 
will  relieve  the  patient  and  hold  the  case  until  you 
can  go.  The  same  procedure  will  often  save  you 
from  going  out  during  the  night. 


CHAPTER  XXVI. 

Eeligious  Rites,  Etc. 

In  Roman  Catholic  families  there  are  four  re- 
ligious rites  that  you  must  always  keep  in  mind: 
(1)  baptism;  (2)  holy  eucharist  or  communion,  (3) 
penance,  (4)  extreme  unction.  According  to  the 
Catholic  belief,  baptism  is  a  sacrament  by  which  the 
child  is  cleansed  of  original  sin.  This  sacrament 
can  be  administered  by  anyone.  It  does  not  matter 
what  your  religious  belief  may  be ;  any  human  being 
can  administer  it.  It  is  better  for  you  to  do  it,  as 
you  are  the  executive  officer.  Usually  when  it  is 
required  in  emergencies  it  is  done  as  follows: 

You  must  pour  ordinary  water,  whether  sterile 
or  not,  on  the  child's  head,  saying  at  the  same  time 
that  you  are  pouring  the  water,  ''I  baptize  thee  in 
the  name  of  the  Father  and  of  the  Son  and  of  the 
Holy  Ghost."  It  is  essential  that  every  word  of  this 
formula  be  uttered ;  be  careful  not  to  omit  the  "ofs," 
as  is  frequently  done. 

In  all  cases  of  difficult  labor  be  prepared  to  ad- 
minister it.  If  you  feel  that  the  child  is  likely  to 
die  before  delivery,  try  to  reach  the  head  with  a 
glass  syringe  filled  with  sterile  water;  while  inject- 
ing, repeat  the  formula  as  above.  If  for  any  reason 
you  cannot  reach  the  child's  head,  then  the  water 
may  be  poured,  or,  better,  injected,  by  means  of  a 

223 


224    BUILDING  A  PROFITABLE  PRACTICE 

fountain  syringe,  the  nozzle  of  which  is  pressed 
against  some  portion  of  the  surface  of  the  child, 
and  while  the  water  is  running,  say,  ' '  If  thou  canst 
be  baptized,  I  baptize  thee  in  the  name,"  etc. 

Whenever  you  are  in  any  doubt  as  to  the  sur- 
vival of  the  child,  soon  after  labor  administer  it 
without  delay.  It  can  do  the  child  no  possible  harm. 
If  there  is  no  great  hurry  and  yet  there  is  danger 
to  the  child,  have  the  family  call  the  priest  to  ad- 
minister it.  Of  course,  there  is  more  ceremony 
attached  to  it  by  the  priest  than  I  have  outlined, 
but  that  is  the  essential  part.  All  of  this  may  seem 
of  little  value  and  importance  to  you,  but  experi- 
ence will  show  you  that  most  Catholic  families  prize 
the  fact  that  the  child  has  been  baptized  before  death 
beyond  thousands  of  dollars  in  money  value.  If 
you  have  been  instrumental  in  accomplishing  this, 
you  will  disarm  any  unfavorable  criticism  resulting 
from  the  death  of  the  infant. 

The  holy  eucharist  and  penance  are  given  to- 
gether in  all  cases  of  illness.  After  baptism,  pen- 
ance is  the  most  essential  sacrament.  In  penance 
the  patient  confesses  his  sins  to  the  priest,  and 
must,  therefore,  be  conscious  when  it  is  administered. 

The  holy  eucharist  consists  in  the  administration 
of  a  wafer  of  unleavened  bread  about  the  size  of  a 
silver  quarter.  The  church  teaches  that  this  wafer 
properly  sanctified  is  the  body  of  Christ.  It  is  ad- 
ministered shortly  after  confession.  When  possible 
the  patient  should  be  fasting  from  the  night  before, 
although  this  is  not  insisted  on  when  the  fasting  in- 


RELIGIOUS  RITES,  ETC.  225 

volves  a  great  hardship,  or  if  there  is  immediate 
danger  of  death. 

The  sacrament  of  extreme  unction  is  usually  ad- 
ministered only  once  during  a  single  illness  and 
then  only  when  there  is  danger  of  death.  Its  aim 
is  to  give  the  patient  strength  and  grace  for  death. 
It  may  be  given  to  the  unconscious  patient.  The 
priest  recites  several  prayers  and  anoints  the  body 
in  various  places  with  holy  oils;  hence  it  is  some- 
times called  anointing. 

In  any  case,  if  the  patient  be  a  Roman  Catholic, 
whether  he  be  a  church-goer  or  not,  if  there  is  any 
likelihood  of  danger  of  death  you  will  do  well  to 
suggest  the  advisability  of  calling  the  priest  to  see 
the  patient.  The  friends  of  the  patient  will  appre- 
ciate this  and  thank  you  for  it.  Don 't  wait  until  the 
patient  is  unconscious.  The  presence  of  the  priest 
never  does  harm;  often,  on  the  contrary,  the  calm 
and  quiet  following  his  visit  has  a  good  effect  on 
the  patient's  condition.  Aside  from  the  spiritual 
standpoint,  the  Catholic  Church  forbids  the  burial 
in  consecrated  ground  of  those  who  fail  to  live  up 
to  her  laws.  This  causes  much  anguish  in  the  minds 
of  the  friends  and  relatives  of  the  deceased.  Never 
antagonize  any  clergyman  in  a  sick  room,  whatever 
his  creed  or  religion  may  be.  It  is  very  rare  that 
what  you  are  doing  for  the  patient  is  so  important 
that  you  cannot  wait  a  few  moments  until  the  clergy- 
man has  finished.  If  he  happens  to  be  a  self-opin- 
ionated, irritable  creature,  then  that  is  all  the  more 
reason  for  your  forbearance,  as  he  may  be  the  means 

15 


226    BUILDING  A  PROFITABLE  PRACTICE 

of  doing  you  far-reaching  harm  by  his  antagonism. 

If  you  provide  for  these  deathbed  sacraments, 
your  wrong  prognosis  will  generally  be  forgotten. 
If  you  fail  to  do  this  and  the  patient  dies  without 
the  attendance  of  the  priest,  no  amount  of  explana- 
tion on  your  part  will  relieve  the  minds  of  the 
friends  as  to  the  eternal  safety  of  the  soul  of  the  de- 
ceased. 

Remember  that  those  of  religious  beliefs,  other 
than  Catholics,  often  wish  to  see  their  clerical  ad- 
viser. 


CHAPTER  XXVII. 

Obstetbic  Cases  and  Emergencies. 

There  are  certain  groups  of  cases  and  emer- 
gencies, the  handling  of  which  often  go'es  to  make 
or  unmake  a  beginner.  It  is  not  my  intention  to  tell 
you  how  to  treat  these  cases,  or  what  medicine  to 
use,  but  to  point  out  the  usage  that  is  commonly 
employed  by  most  successful  doctors.  These  emer- 
gencies mean  so  much  to  the  young  man  that  he 
should  be  prepared  to  handle  them,  so  as  to  protect 
himself  as  well  as  the  patient.  The  most  frequent 
of  these  emergencies,  and  the  largest  factor  in  the 
practice  of  many,  is  the  maternity  case,  and  the  suc- 
cessful handling  of  the  patient  and  friends  is  of 
paramount  importance. 

Some  fine  evening  there  will  be  ushered  into 
your  office,  accompanied  by  a  patient  of  your  own, 
a  pregnant  woman.  On  such  an  occasion  it  is  well 
to  look  pleased  and  be  very  cordial.  After  a  few 
preliminaries  as  to  the  weather,  etc.,  begin  by  ask- 
ing her  when  she  menstruated  last,  when  she  first 
felt  life,  etc.,  and  then  announce  when  labor  is  likely 
to  take  place,  being  careful  to  say  that  all  of  such 
estimates  can  at  best  be  approximately  correct. 
Examine  her  carefully,  her  breasts,  etc.  In  country 
places  the  primipara  is  very  loath  to  submit  to  a 
vaginal  examination.     Do  not  expose  the  patient 

227 


228    BUILDING  A  PROFITABLE  PRACTICE 

under  any  circumstances,  nor  cause  any  pain.  If 
she  is  very  timid  and  sensitive,  examine  only  exter- 
nally the  first  time;  later  when  you  have  her  con- 
fidence make  a  vaginal  examination.  In  all  such 
examinations  be  scrupulously  clean.  If  the  clothing 
must  be  elevated,  throw  a  sheet  over  the  patient. 
After  examining  the  breasts  and  giving  general  di- 
rections as  to  the  bowels,  stomach,  urine,  etc.,  take 
up  the  nurse  question.  It  will  save  you  much  time 
and  worry,  if  you  will  early  in  your  practice  make 
up  a  list  of  nurses  at  various  prices  and  qualities. 
If  the  patient  is  a  primapara  insist  on  a  good  com- 
petent nurse.  In  most  of  the  families  of  your  early 
practice  the  nurse  must  cook  and  keep  house,  as  well 
as  care  for  the  patient.  Such  nurses  receive  from 
$8  to  $15  per  week.  Often  the  patient  has  already 
engaged  a  nurse  before  she  comes  to  see  you.  It 
is  well  not  to  be  too  insistent  on  a  change  under  the 
circumstances,  because  the  one  she  has  already  en- 
gaged will  probably  discredit  you  and  induce  her 
to  have  another  doctor  should  you  object  to  her 
presence. 

After  you  have  finished  your  examination,  as- 
sure her  that  ever5i;hing  will  be  all  right.  In  the 
multipara  it  is  not  often  necessary  to  examine  the 
patient.  The  patient  will  now  ask  you  your  fee.  If 
she  does  not,  you  may  make  a  suggestion  that  some 
financial  understanding  should  be  had.  If  you  know 
the  people,  this  is  not  a  necessity.  The  question  of 
the  size  of  the  fee  must  be  decided  by  the  custom 
of  the  neighborhood.    A  man  who  earns  but  $15  per 


OBSTETRIC  CASES  AND  EMERGENCIES  229 

week  can  scarcely  pay  much  more  than  $15  for  a 
confinement. 

If  she  cannot  pay  the  fee,  take  the  case  at  what- 
ever price  the  family  can  afford,  explaining  that 
you  do  it  as  a  favor.  Obstetrics  supplies  the  kin- 
dling wood  for  the  fire  of  your  future  practice. 
However,  do  not  make  it  a  practice  of  underbidding 
for  it;  poverty  of  the  patient  is  the  only  reason  for 
lowering  your  price. 

A  large  clientele  among  primiparas  in  the  first 
years  of  your  practice,  although  it  is  a  severe  strain 
at  the  time,  makes  the  professional  path  easier  in 
later  life.  It  is  well  to  seem  anxious  to  take  a  labor 
case  as  women  then  think  that  you  take  a  special 
interest  in  that  kind  of  work. 

After  the  fee  question  has  been  settled,  write 
down  the  name  and  address  of  the  patient  and  date 
of  expected  confinement  in  your  visiting  book;  also 
make  a  duplicate  copy  of  this  on  the  back  of  one 
of  your  visiting  cards;  give  it  to  her  and  tell  the 
patient  to  send  that  card  when  she  goes  into  labor. 
Instruct  her  that  (when  the  labor  pains  commence) 
she  should  send  for  the  nurse  at  once;  also,  if  it 
is  during  the  day,  that  you  should  be  notified,  so 
that  you  will  be  ready  in  case  you  are  needed.  When 
the  pains  come  every  five  minutes,  in  most  cases  of 
primiparae  labor  is  still  three  or  four  hours  off;  in 
multiparae,  in  one  to  two  hours.  Explain  this  to  the 
patient  that  she  may  not  be  alarmed,  and  that  you 
are  not  needlessly  disturbed  at  night. 

Have  the  urine  sent  regularly  and  explain  the 


230    BUILDING  A  PROFITABLE  PRACTICE 

importance  of  this;  otherwise,  you  will  find  it  gen- 
erally neglected.  Some  men  even  go  so  far  as  to 
send  postals  reminding  the  patient  of  its  failure  to 
arrive  at  the  appointed  day.  This  appointing  of 
one  day  in  the  week  to  send  the  urine  is  a  great  con- 
venience when  many  urines  must  be  examined.  Also 
give  the  patient  a  list  of  the  very  few  things  that  are 
necessary  for  her  to  have,  as  boric  acid,  cotton,  etc. 
Tell  her  how  to  make  cheesecloth  and  cotton  nap- 
kins and  instruct  her  to  come  to  you  at  the  least  sign 
of  disturbed  vision,  persistent  headache  and  dizzi- 
ness. 

In  the  early  days  of  your  practice,  with  time 
hanging  on  your  hands,  it  is  well  occasionally  to 
drop  in  on  your  pregnant  patients  when  in  their 
neighborhood.  They  think  a  great  deal  of  it.  Stay 
long  enough  only  to  inquire  as  to  their  functions, 
etc.,  and  make  no  charge. 

When  called  to  a  labor  case,  go  at  once.  If  you 
have  an  obstetric  cushion,  take  it  along.  It  makes 
a  friend  of  the  nurse.  Take  your  bag  containing 
chloroform,  ergot,  some  antiseptic,  a  fountain 
syringe,  sutures,  needles  and  holder,  and  a  pair  of 
obstetric  forceps;  sterile  gauze  in  the  shape  of 
sealed  bandages,  or  otherwise,  a  scale  for  weighing 
the  baby,  and  a  pair  or  two  of  sterile  rubber  gloves. 
On  entering  the  room  be  as  cordial  as  possible ;  speak 
to  the  woman  for  a  minute  or  two  and  then  clean 
up.  Rubber  gloves  often  save  the  busy  man  the 
time  spent  in  scrubbing  up.  Then  instruct  the  pa- 
tient to  lie  down  and  cover  her  over  with  a  sheet; 


OBSTETRIC  CASES  AND  EMERGENCIES  231 

reassure  the  patient  that  you  will  not  hurt  her, 
that  you  will  be  as  gentle  as  a  child,  etc.  Go  slowly ; 
determine  the  frequency  of  pains,  etc.;  the  bag  of 
waters,  condition  of  bowels,  urine,  feeling  of  life. 
Now,  if  the  case  be  a  primipara  and  the  os  be  di- 
lated to  admit  one  finger,  you  can  make  up  your 
mind  that  labor  is  at  least  ten  hours  off.  If  the  os 
be  the  size  of  a  silver  dollar  and  fairly  thick,  it  is  at 
least  from  three  to  four  hours  off.  In  a  multipara, 
when  the  os  is  the  size  of  a  silver  dollar  with  fre- 
quent pains,  it  is  better  to  stay  with  the  patient.  If 
the  OS  is  small  and  only  admits  two  fingers  in  a 
primipara,  tell  her  that  everything  is  all  right,  but 
that  it  will  take  some  time.  The  less  said  as  to  the 
length  of  time,  the  better,  for  if  you  say  two  hours 
and  it  is  longer,  you  will  hear  that  two-hour  story 
a  dozen  times,  or  more.  If  you  believe  it  is  a  ques- 
tion of  three  to  four  hours,  you  can  go  home,  telling 
them  that  you  will  return  at  such  a  time,  and  then 
come  promptly. 

Always  be  pleasant,  no  matter  how  irritable  the 
people  are.  In  primiparas  when  the  os  is  small  and 
pains  frequent,  sleep  and  much  needed  rest  will 
often  follow  a  good  sized  dose  (gr.  V^-gr.  I/2)  of 
morphine  hypodermically ;  chloral  and  bromide 
will  do  much  the  same  thing.  In  multiparas  with 
slow  pains  every  fifteen  minutes  for  a  day  or  so, 
with  no  obstruction,  a  15-gr.  dose  of  quinine  bisul- 
phate  will  often  hurry  matters  along;  pressing  on 
one  side  of  the  clitoris  or  turning  patient  on  the 
side  will  frequently  start  a  pain.     After  waiting 


232    BUILDING  A  PROFITABLE  PRACTICE 

sufficient  time  and  no  progress — with  the  formation 
of  a  small  caput,  it  is  well  to  say,  that  *'if  something 
doesn't  soon  happen,  we  will  have  to  think  of  giving 
you  chloroform  and  delivering  with  forceps."  Do 
this  about  half  an  hour  beforehand  to  let  the  thought 
of  relief  filter  into  the  patient's  mind,  and  she  will 
cry  for  the  forceps.  Before  doing  so,  explain  to  the 
husband  and  her  that  you  do  not  wish  to  apply  the 
forceps,  but  that  the  mother's  strength  is  fast  giv- 
ing out  and  it  is  mostly  for  her  sake  you  are  doing 
it.  At  the  same  time  there  is  a  swelling  on  the 
child's  head  which  shows  that  the  pressure  inside 
is  acting  badly  on  the  child  and  that  it  is  necessary 
to  do  this  to  save  its  life.  Explain  that  you  have 
waited  long  enough  for  nature,  etc. 

The  application  of  forceps  or  version  always 
adds  to  mortality  and  to  the  morbidity  of  the  child, 
and  if  you  do  not  fortify  yourself  this  way  before- 
hand you  will  be  blamed  if  the  child  is  born  dead. 

When  all  preparations  are  made,  the  question 
arises,  ''Shall  I  call  for  another  doctor?"  Do  this 
by  all  means,  if  it  is  possible  to  do  so;  otherwise, 
by  means  of  a  sheet  over  the  patient's  head  tie  the 
patient's  legs  in  the  lithotomy  position  and  have 
the  nurse  administer  the  anaesthetic.  The  anass- 
thesia  should  not  be  very  deep.  If  you  anticipate 
no  trouble  in  putting  in  the  forceps,  sometimes  the 
husband  can  hold  the  legs.  It  is  generally  better 
to  have  strangers  do  this.  If  the  family  are  Catho- 
lics, have  some  sterile  water  and  when  the  head 
appears  baptize  per  formula  on  page  223.    Explain 


OBSTETRIC  CASES  AND  EMERGENCIES  233 

this  to  the  mother  before  anaesthesia  and  to  the 
family  afterwards. 

Be  always  prepared  to  sew  and  do  most  of  it  if 
possible  before  the  delivery  of  the  after-birth,  as  the 
patient  is  not  very  sensitive  then.  If  much  sewing 
must  be  done,  it  is  better  to  wait  till  the  after-birth 
is  removed  and  reansesthetize  the  patient.  Be  sure 
that  the  child  cries  well.  If  another  doctor  has  been 
called  in,  find  out  what  his  charges  are;  $5  or  $10 
for  the  anaesthesia,  or  more,  if  he  had  much  to  do. 
Call  the  husband  aside  and  tell  him  to  pay  this  man 
now  as  he  is  a  stranger,  etc.  He  will  ask  you,  ' '  How 
much?"  and  you  can  ask  the  doctor  then  and  there  in 
front  of  the  husband  and  see  that  he  is  paid,  other- 
wise it  may  come  out  of  your  pay. 

If  the  case  progresses  normally,  when  the  head 
begins  to  appear  at  the  perineum,  instruct  the  nurse 
to  administer  chloroform  at  each  pain.  Let  her  give 
just  enough  of  it  to  rob  the  patient  of  acute  con- 
sciousness. As  the  head  comes  out  further  increase 
the  anaesthesia,  so  that  at  delivery  she  is  just  un- 
conscious, then  stop  it.  This  little  procedure  will  do 
more  to  spread  your  fame  than  any  other  thing  in 
the  obstetric  line.  It  should  be  perfectly  safe.  In 
some  cases  you  can  do  this  yourself  with  the  left 
hand  and  guide  the  child  ^s  head  with  the  right  hand. 
After  the  cleaning-up  process,  always  weigh  the 
baby ;  examine  it,  and  leave  directions  with  the  nurse. 
It  is  well  to  call  on  the  same  day  again  and  see  that 
the  urine  is  voided.  Some  patients  must  get  up  on 
the  floor  on  a  vessel  before  they  succeed  in  passing 


234    BUILDING  A  PROFITABLE  PRACTICE 

urine.  It  does  no  harm.  At  each  visit  do  not  neg- 
lect to  look  at  the  baby  and  make  at  least  a  super- 
ficial examination.  At  the  end  of  the  deliverj'^  com- 
pliment the  nurse  on  her  care,  etc.  Within  the  next 
forty-eight  hours  she  will  have  sung  an  accompani- 
ment of  your  praise  to  that  of  your  patient  to  a 
dozen  or  more  women.  On  such  occasions  all 
women  seem  more  susceptible  than  at  other  times 
and  lasting  impressions  are  easily  made. 

On  the  day  before  your  last  visit,  tell  the  patient 
that  you  will  make  your  last  call  on  the  following 
day.  This  will  be  a  strong  hint  to  her  that  you  ex- 
pect to  be  paid  then. 

Emergency  obstetric  cases  are  notoriously  poor 
pay.  Endeavor  by  all  means  to  be  paid  before  go- 
ing out  to  such  cases.  If  this  is  not  possible,  go  any- 
how. Try  to  get  some  money  at  the  delivery  of  the 
child;  you  will  seldom  get  any  at  a  later  period. 

If  a  circumcision  is  necessary,  say  so,  and  if  the 
people  wish  it  done,  do  it  while  the  nurse  is  still  on 
the  case. 

AN    ECLAMPSIA. 

When  called  to  see  a  patient  who  is  suffering 
from  severe  uterine  hemorrhage  or  eclampsia,  at 
once  send  some  one  out  for  another  doctor;  such 
cases  require  the  activities  of  two  doctors.  Have 
a  definite  plan  in  mind  to  meet  the  emergency.  If 
it  be  an  eclampsia,  administer  chloroform  during 
the  convulsion  and  give  an  enema  of  chloral  and 
bromide,  keeping  the  patient  under  anaesthetic  until 


OBSTETRIC  CASES  AND  EMERGENCIES  235 

the  chloral  acts.  After  you  have  done  this,  you  can 
follow  any  course  of  treatment  that  you  have  been 
taught  proper  for  such  conditions. 

HYSTERIA. 

When  called  to  a  case  of  hysteria,  don't  waste 
time  asking  questions,  but  as  soon  as  you  make  your 
diagnosis  give  a  hypo  of  apomorphine,  gr.  1/20  to 
1/12.  Don't  make  fun  of  such  cases,  nor  speak 
crossly;  they  need  just  as  much  gentleness  as  any 
serious  case.  Cold  water  showers  during  the  con- 
vulsion will  prevent  their  ever  sending  for  you 
again,  and  you  lose  the  case  by  such  a  method. 


CHAPTER  XXVIII. 

Abobtions,  Etc. 

When  called  to  a  miscarriage,  don*t  call  it  an 
abortion,  although  technically  it  may  be  called  so. 
Before  you  do  anything,  say  in  the  presence  of  a 
third  party:  **0f  course,  this  is  a  miscarriage,'* 
as  then  no  one  can  say  that  your  examination  re- 
sulted in  the  production  of  the  miscarriage.  After 
thorough  antisepsis,  an  examination  should  be  mado. 

It  is  a  curious  fact,  that  once  a  woman  confesses 
to  you  that  a  criminal  abortion  has  been  performed, 
she  rarely  likes  to  meet  you  again;  she  generally 
feels  guilty,  if  there  is  any  honesty  in  her  makeup. 
For  this  reason  she  is  very  apt  to  send  for  another 
doctor,  whenever  there  is  any  other  sickness  in  the 
family.  So  it  is  well  never  to  appear  to  think  that 
the  abortion  was  produced  unlawfully.  Of  course, 
some  women  resort  to  it  so  often  that  they  think 
nothing  of  it;  but  most  women  feel  that  it  is  wrong 
and  they  do  not  like  to  have  you  think  that  they 
could  do  wrong.  They  reason  that  you,  knowing 
that  they  have  once  done  wrong,  will  naturally  think 
them  likely  to  do  wrong  in  other  things.  At  least 
that  is  one  explanation  of  why  such  people  move  out 
of  a  neighborhood  and  change  doctors. 

After  finishing  your  examination,  it  is  well  to 
call  the  husband  aside,  or  else  in  the  presence  of 
the  wife  tell  him  of  the  condition.    Elaborate  on  the 

£36 


ABORTIONS,  ETC.  237 

dangers,  if  you  believe  it  to  be  a  criminal  case. 
Then,  if  the  os  be  open,  tell  him  that  you  are  going 
to  try  to  remove  the  after-birth,  which  is  causing 
pain  and  bleeding.  Do  so  as  far  as  possible  man- 
ually. If  you  fail  to  remove  it,  pack  the  uterus  and 
vagina.  This  should  be  done  in  any  case  if  the 
bleeding  is  at  all  severe ;  a  2-inch  sterile  gauze  roller 
bandage  makes  excellent  material,  as  it  is  so  easily 
removed.  A  bent  tablespoon  will  often  serve  in  the 
absence  of  a  speculum,  and  a  pair  of  long  scissors 
for  a  forceps.  If  the  pain  is  severe,  as  it  often  is 
before  the  os  is  opened,  give  a  hypodermic  of  mor- 
phine (gr.  1/4)  and  you  may  go  home  and  rest.  If 
the  bleeding  has  lessened  considerably,  leave  a  pre- 
scription for  1  teaspoonful  of  ergot  every  3  hours. 
Explain  that  doctors  do  not  desire  such  cases  on 
account  of  the  unpleasant  notoriety  that  may  follow, 
if  the  case  should  take  a  serious  turn. 

If  after  the  manual  curetting  the  discharge  does 
not  stop  nor  the  pain  cease,  it  is  well  to  suggest  a 
curettage  under  ether.  Insist  on  it  the  next  day,  as 
after  a  thorough  cleaning  of  the  uterus  the  patient 
should  be  free  from  pain  and  discharge.  If  you  feel 
the  least  doubt  as  to  the  safe  outcome  of  the  case, 
by  all  means  call  in  counsel.  You  should  do  this  in 
any  event  if  the  temperature  and  pulse  remain 
high  after  you  have  cleaned  out  the  uterine  cavity. 
A  prominent  obstetrician  naively  suggests  calling  a 
coroner's  physician  as  consultant. 

Your  consultant  should  be  a  friend  of  your  own. 
Explain  to  the  people  the  necessity  of  such  consul- 


«38    BUILDING  A  PROFITABLE  PRACTICE 

tation.  Ask  them  to  pay  him  at  once.  If  they  will 
not  agree  to  this,  bring  in  a  friend  anyhow  for  your 
own  protection.  This  will  help  you  if  there  is  any 
trouble  with  the  coroner's  office.  The  best  safe- 
guard in  such  cases  is  a  good  clean  reputation.  If 
the  patient  is  moribund,  have  the  coroner  take  the 
ante-mortem  statement  and  be  present  when  he  does, 
so  as  to  protect  yourself.  Many  physicians  insist 
on  a  consultation  in  all  such  cases  when  the  patient 
is  a  stranger.  Fortunately  most  abortions  occur 
within  the  first  three  months  and  are  seldom  seri- 
ous; after  the  third  month  there  is  much  more 
danger. 

Do  not  tell  the  neighbors  that  Mrs.  S.  has  had 
a  miscarriage.  Be  sure  to  inform  one  or  two  of  the 
immediate  family  members  that  such  is  the  case,  or 
have  the  patient  tell  them  in  your  presence.  If  you 
are  afraid  that  some  odium  may  be  cast  on  yourself 
by  reason  of  your  attending  her,  you  may  cause  the 
patient  to  also  sign  a  paper,  acquitting  you  from  all 
participation  and  mentioning  the  name  of  the  guilty 
party. 

Some  evening  about  dusk  a  young  woman  or  per- 
haps a  married  lady  will  be  ushered  into  your  office. 
After  one  or  two  long  breaths,  and  while  furtively 
casting  her  eyes  about  the  office,  she  will  inform  you 
that  she  has  been  run  down  and  has  missed  her 
monthly  period;  she  wishes  something  to  bring  her 
around  again.    Be  suspicious  at  once. 

It  is  not  necessary  for  me  to  expatiate  on  the 
fact  that  under  no  circumstances  whatsoever  should 


ABORTIONS,  ETC.  239 

you  yourself  be  guilty  of  this  foul  crime.  It  is  al- 
ways a  murder.  The  woman  may  be  excused — no 
one  else  can  possibly  be  so,  when  you  are  consulted 
on  this  matter,  as  you  surely  will  be,  by  some  woman ; 
be  she  married  or  single,  prepare  at  once  to  answer 
"No."  She  will  give  you  the  best  reasons  as  she 
sees  them ;  they  are  all  as  old  as  humanity :  that  she 
cannot  afford  it;  that  her  husband  will  drive  her 
out;  that  her  former  physician  said  that  she  would 
die  if  she  had  another  baby ;  or,  if  she  is  unmarried, 
that  she  will  kill  herself  first;  that  she  will  be  an 
outcast,  etc.  Sympathize  with  her,  if  you  will,  but 
always  firmly  say  *'No" — ^that  you  do  not  believe 
that  any  medicines  are  of  any  use;  that  you  would 
not  know  how  to  do  the  deed  anyhow. 

No  matter  what  the  tears,  the  money,  the  friend- 
ship may  mean,  say  *'No."  I  do  not  say  this  alone 
from  any  moral  standpoint,  but  never  has  a  man 
achieved  success,  so  considered  by  himself,  who  has 
ever  done  otherwise;  once  this  crime  is  done  the 
descent  to  inferno  is  easy  and  we  have  thousands 
of  such  wrecks  on  that  highway.  Some  men  do 
amass  considerable  riches  in  this  way,  but  without 
exception  they  are  unhappy  and  generally  lose  it. 
When  a  nervous  woman  comes  to  you,  saying,  "Doc- 
tor, I  am  five  days  overdue,  I  am  worried  and  want 
you  to  do  something  for  me,"  etc.,  she  does  not 
really  believe  that  such  an  early  pregnant  condition 
means  a  life,  but  you  in  your  own  breast  know  that 
one  day  conception  is  the  same  physiologically  as  a 
three  or  nine  months'  pregnancy.     When  such  a 


240    BUILDING  A  PROFITABLE  PRACTICE 

woman  comes  to  you,  she  is  probably  a  good  patient, 
the  mother  of  a  family  you  have  attended,  and  you 
may  think  that  you  are  going  to  lose  the  family  if 
you  do  not  do  something  for  her  (this  is  rarely  the 
case).  Do  not  sit  down  and  write  a  prescription  for 
her,  but  explain  that  such  a  passing  of  a  period  is 
quite  common  in  married  women  ( she  will  shake  her 
head  at  this  and  say:  ''It  is  not  so  with  me") ;  as- 
sure her  that  this  often  occurs,  and  that  there  must 
be  a  first  time  in  all  such  cases;  that  there  are  no 
medicines  that  will  bring  on  the  menstruation,  if  it 
is  a  true  conception,  but  if  it  is  what  you  believe  it 
to  be,  viz.,  a  rundown  condition  of  the  body,  that  a 
five-grain  Blaud  iron  pill  taken  three  times  a  day 
for  two  or  three  weeks  will  bring  a  return  of  the 
menses.  Don't  give  a  prescription,  but  tell  her  to 
get  fifty  or  a  himdred  such  pills.  I  have  known  good 
men  to  get  an  evil  reputation  in  neglecting  this 
simple  expedient.  They  have  given  a  bottle  of  some 
harmless  tonic  or  a  prescription  for  the  same,  and 
the  woman  has  menstruated  as  she  would  have  any- 
way; as  a  consequence,  the  patient  with  a  knowing 
wink  has  told  all  of  her  neighbors  that  her  doctor 
gave  her  something  that  has  brought  her  around. 
When  these  neighbors  wish  to  avoid  the  ordeals  of 
pregnancy,  they  naturally  will  come  to  the  specialist 
who  brought  Mrs.  So-and-So  around — much  to  your 
mortification.  Your  confreres  will  hear  of  such 
things,  and  if  you  have  not  a  perfectly  clean  reputa- 
tion they  will  despise  you  and  by  their  sneering 
smiles  at  the  mention  of  your  success  show  that  the 


ABORTIONS,  ETC.  241 

dollar  or  two  you  have  received  is  a  grain  of  sand 
compared  with  the  mountain  of  evil  in  the  shape  of  a 
shady  reputation  that  results  from  this  indiscretion. 

Don't  send  a  patient  who  desires  an  abortion 
committed  to  a  man  whom  you  know  is  an  abortion- 
ist. If  you  do,  you  are  just  as  guilty  as  he  who  does 
the  abortion.  If  you  are  asked  to  recommend  some 
one  who  does  this  work,  say  that  you  have  no  deal- 
ings with  such  a  man. 

After  having  failed  to  work  on  your  sympathy, 
your  patient  will  try  to  pierce  your  armor  of  integ- 
rity by  working  on  your  jealousy,  announcing  that 
your  neighbor,  Dr.  So-and-So,  does  it  and  that  she 
will  go  to  him  or  to  someone  else.  Don't  be  intimi- 
dated. Better  a  thousand  times  to  live  on  bread  and 
water  than  to  have  aU  sorts  of  money,  with  the  con- 
sciousness of  the  fact  that  you  are  a  murderer.  You 
may  explain  to  your  patient  that  anyone  who  will 
commit  murder  for  money  or  out  of  sympathy,  will 
do  the  same  thing  to  herself  for  the  same  motives.  To 
physicians,  in  the  last  analysis  abortion  and  murder 
are  synonymous  terms — all  drivel  with  which  guilty 
people  like  to  console  themselves,  such  as  that  there 
is  no  life  until  the  fourth  or  fifth  month,  to  the  con- 
trary notwithstanding.  Remember,  that  people  who 
want  this  sort  of  work  done  are  never  lasting  pa- 
tients; their  lack  of  moral  principle  implies  a  lack 
of  any  other  form  of  loyalty. 

A  woman,  after  she  has  recovered,  despises  in 
her  secret  heart  such  a  man  and  cannot  believe  in 

16 


242    BUILDING  A  PROFITABLE  PRACTICE 

him;  thereafter  she  will  seldom  trust  her  children's 
lives  in  his  care  for  any  lengthy  period. 

A  trick  sometimes  practised  on  young  doctors 
is  this:  a  woman  who  finds  herself  pregnant  will 
call  and  explain  that  she  has  some  female  complaint ; 
she  will  deny  that  she  has  missed  a  period.  In  the 
course  of  the  examination,  if  you  fail  to  pass  a  sound 
in  the  uterus,  she  will  be  unsatisfied  and  will  ask  you 
to  do  so  to  be  sure  that  there  is  no  tumor  there,  etc. 
So  make  it  a  rule  never  to  put  a  sound  into  the 
uterine  cavity  unless  you  are  sure  it  is  empty. 
Catheterization  of  the  uterus,  the  fitting  of  condoms 
in  the  uterus,  fooling  women  by  telling  them  that 
you  have  tipped  their  womb,  etc.,  are  all  of  them  de- 
grading and  morally  wrong  and  no  good  practice 
has  ever  resulted  therefrom. 


CHAPTER  XXIX. 
The  Doctor  as  a  Specl^list. 

Patients  appreciate  anyone  who  shows  that  he 
takes  an  interest  in  their  case,  by  his  thorough  ex- 
aminations. They  like  to  see  one  earn  his  fee ;  they 
can  seldom  understand  that  his  writing  a  few  words 
on  a  piece  of  paper  is  value  received  for  their  money. 

The  only  way  to  make  your  profession  pay  a 
fair  return  is  to  practise  all  of  the  specialties. 

Learn  to  perform  the  four  or  five  general  opera- 
tions that  are  necessary  for  most  cases  of  nasal  sur- 
gery, i.e.,  removal  of  turbinates  and  polyps,  the 
straightening  of  the  septum,  tonsillectomy  and  ade- 
nectomy. 

In  the  eye,  the  opening  of  the  nasal  duct ;  the  re- 
moval of  a  foreign  body  from  the  cornea  and  the 
measurement  of  glasses. 

In  genito -urinary  surgery,  the  cutting  of  stric- 
tures, external  and  internal,  and  the  passage  of  a 
filiform.    Mayhap  cystoscopy. 

In  gynaecology,  a  curettement,  perineorrhaphy  and 
trachelorrhaphy,  and  perhaps  the  opening  of  the 
cnl-de-sac  of  Douglas. 

When  you  can  do  these  things,  there  are  few 
cases  that  you  will  have  to  turn  over  to  the  spe- 
cialist. It  is  true  that  perhaps  you  cannot  get  the 
fee  that  the  specialist  does  for  the  same  work,  yet 

£4S 


244    BUILDING  A  PROFITABLE  PRACTICE 

you  can  get  a  great  deal  more  than  your  ordinary 
fee,  and  can  suit  yourself  as  to  the  time  of  doing 
the  work.  In  the  meantime  the  patient  will  not  be 
milked  dry,  as  he  or  she  generally  is  after  spending 
a  few  weeks  or  months  in  the  sanatorium  of  the 
specialist. 

During  the  past  decade  the  use  of  glasses  has 
become  almost  universal.  The  time  was  when  all 
of  the  fitting  of  glasses  was  in  the  hands  of  the 
regular  physicians.  To-day,  as  a  result  of  apathy 
of  the  profession,  the  legislatures  of  sixteen  States 
place  ignorant  laymen  on  a  par  with  you,  as  far  as 
the  treatment  of  the  eye  is  concerned.  There  is  no 
great  secret  in  acquiring  the  ability  to  fit  glasses. 
When  an  ignorant  layman  can  successfully  do  it, 
there  is  no  reason  why  you  cannot  do  it  better.  A 
trial  case,  an  ophthalmoscope  and  a  work  on  refrac- 
tion will  not  cost  more  than  $10  or  $15.  Your  time 
is  not  so  valuable  that  you  cannot  devote  a  half  hour 
to  such  an  examination.  By  so  doing,  you  should 
be  able  to  treat  all  of  the  simple  refractive  errors. 
If  the  case  be  a  difficult  one,  you  may  send  it  to  a 
specialist.  Most  of  the  cases  that  need  glasses  are 
quite  easy  to  handle.  You  can  get  a  double  fee, 
and  even  though  you  only  received  an  office  fee,  it 
is  better  than  throwing  the  money  away  by  allowing 
a  poor  patient  to  seek  an  irregular  or  a  department 
store  physician.  There  is  an  element  of  profit  in 
the  cost  of  the  glasses,  which  you  yourself  can  se- 
cure if  you  wish.  If  you  send  the  patient  to  an 
optician  for  the  prescription,  you  cannot  be  sure 


Corner  of  an  office  equipped  to  specialize  on  the  eye. 


THE  DOCTOR  AS  A  SPECIALIST         245 

that  the  frames  are  placed  properly,  nor  can  you  be 
certain  that  the  patient  is  satisfied.  Your  profit  in 
trying  on  the  glasses  yourself  will  compensate  you 
for  the  extra  trouble  involved.  Certainly  this  is 
true  in  country  places. 

A  few  practical  lessons  can  be  obtained  in  any 
metropolitan  centre,  if  you  do  not  have  the  requisite 
amount  of  courage  to  begin  independently  yourself. 
I  do  not  mean  that  you  should  pose  as  a  specialist, 
but  that  you  should  handle  the  ordinary  cases  that 
come  to  your  office.  The  patient  would  rather  pay 
you  for  the  work  than  go  to  an  optician  who  has  not 
the  esprit  de  corps  of  a  profession  to  keep  him 
honest.  Every  patient  that  you  must  turn  over  to 
another  department  of  medicine  spells  failure  for 
you,  as  far  as  that  patient  is  concerned. 


CHAPTER  XXX. 
Automobile  vebsus  Hobse  and  Cabbiage. 

As  soon  as  you  can  afford  it,  you  should  pur- 
chase an  automobile.  Six  hundred  dollars  will  se- 
cure one  that  for  all  your  purposes  is  as  good  as 
the  best.  If  you  can  take  care  of  it  yourself  and  see 
to  its  cleansing  in  a  shed  in  the  yard  where  you 
live  the  cost  will  not  be  more  than  twenty  dollars 
per  month;  if  you  must  store  it  in  a  garage,  from 
$30  to  $40  per  month.  A  larger  car  and  a  boy  to 
ride  with  you  will  cost  a  hundred  or  more  per 
month. 

To  the  physician  more  than  to  any  other  member 
of  the  community  the  automobile  is  indispensable. 
Business  can  wait  if  need  be,  but  the  work  of  the 
physician  requires  prompt  attention  at  all  times. 
The  one  who  uses  the  machine  considerably  for 
pleasure  is  apt  to  feel  the  need  of  an  increase  in  his 
income,  while,  on  the  other  hand,  the  one  who  uses 
it  largely  for  practice  will  surely  add  to  his  income. 
It  enables  one  to  cover  more  ground  and  see  more 
patients  and  still  have  more  time  for  study  and 
pleasure  than  before  its  advent. 

It  easily  saves  three  hours  a  day  for  the  busy 
man.  The  ability  to  hold  patients  who  in  moving 
long  distances  would  otherwise  have  been  lost  to 
other  physicians;  the  gain  in  availability  to  the 

246 


AUTOMOBILE  VS.  HORSE  AND  CARRIAGE  M7 

patient  at  his  house  and  punctuality  in  the  observ- 
ance of  office  hours  are  elements  that  cannot  be 
computed.  This  is  especially  so  in  obstetrical 
work,  as  it  brings  the  confinement  case  almost  to 
your  door  by  the  quickness  with  which  you  can  come 
and  return. 

If  a  car  be  chosen  for  professional  work  only, 
then  a  runabout  is  the  type.  In  the  city  a  light  car, 
in  the  country  a  heavy  car  of  30-horsepower.  For 
combined  business  and  pleasure,  a  four-passenger 
car  is  the  better  fitted. 

Aside  from  its  usefulness,  there  is  a  certain 
amount  of  advertisement  in  having  a  car.  The  lay- 
man is  apt  to  judge  that  the  man  who  drives  a  car 
must  have  an  extensive  practice;  furthermore,  it 
obviates  the  necessity  of  standing  amd  talking  to 
patients  that  one  meets  when  walking.  In  so  doing, 
many  an  otherwise  curbstone  prescription  becomes 
an  office  call. 

On  comparing  the  cost  of  auto  and  horse  and 
buggy,  the  Journal  of  the  American  Medical  Asso- 
ciation, in  a  statistical  inquiry,  found  that  the 
average  cost  of  outfit  for  horse  and  buggy  was 
$486.  The  average  annual  cost  of  maintenance  was 
$356.85;  average  mileage,  2680.  For  a  car  under 
$1000,  the  average  cost  was  $747.60;  average  cost 
of  maintenance,  $282.95;  average  mileage,  5000. 
For  the  more  expensive  cars  the  cost  of  mainte- 
nance is  very  much  greater.  The  subjoined  table 
from  the  same  authority  is  more  nearly  represen- 
tative of  the  cost  in  the  large  cities : 


248    BUILDING  A  PROFITABLE  PRACTICE 

$3000  Cab  $1200  Cab 

Lastinq  Lasting 

6  Ybs.,  4  Ybs., 

40,000  30,000 

Mileage.  Mileaqe. 

Depreciation  for  year $500  $300 

Interest  6  per  cent,  per  year 180  72 

Two  sets  4-inch  tires  per  year 320  184 

GaBoline,  oil,  repairs,  etc 200  200 

$1,200  $756 

Cost  per  month   $100  $63 

Of  course,  in  some  sections  at  some  seasons  the 
horse  is  still  a  necessity.  If  you  do  own  a  horse, 
then  it  is  almost  a  necessity  to  have  a  driver.  This 
is  especially  true  in  the  city,  because  you  are  never 
quite  sure  that  he  will  not  run  away  or  some  acci- 
dent happen.  "When  any  such  fear  exists,  you  will 
not  be  quite  contented  while  examining  your  pa- 
tient, and  it  makes  a  bad  impression  to  run  to  the 
window  every  few  minutes  to  see  if  the  horse  is 
still  there.  A  red,  or,  better,  green  cross  on  the 
front  and  rear  of  the  car  will  indicate  that  you  are 
a  physician.  In  some  places  it  will  entitle  you  to  the 
right  of  way  over  other  vehicles  and  grant  you 
some  immunity  from  speed  ordinances ;  at  the  same 
time,  it  is  a  legitimate  form  of  advertisement. 


CHAPTEE  XXXI. 

On  Drugs  and  the  Pharmacist. 

Soon  after  you  have  opened  your  office,  the 
nearby  druggist  will  probably  present  you  with  pre- 
scription pads  with  your  name  and  address  above 
and  his  own  on  the  bottom  or  on  the  back  of  the 
page.  Unless  there  be  some  favors  shown  to  you 
by  a  certain  druggist,  it  is  better  to  tear  off  the 
name  of  the  druggist  from  the  bottom  of  the  pad. 
If  the  druggist  helps  you,  of  course  that  is  a  dif- 
ferent matter.  Certainly,  after  you  are  well  estab- 
lished, it  is  better  not  to  appear  to  be  partial  to  any 
one  druggist,  unless  you  really  believe  that  he  has 
better  medicines  and  is  more  honorable  than  his 
fellows.  To  single  out  one  druggist  and  send  the 
patient  to  him  begets  the  suspicion  in  the  minds  of 
patients  that  there  are  some  commission  arrange- 
ments between  you  and  him  on  such  prescriptions. 
This  commission  business  is  still  unfortunately 
practised  in  some  country  towns,  but  is  fast  dying 
out.  Never  try  to  do  such  a  thing.  It  is  bound  to 
be  found  out  sooner  or  later  to  your  detriment,  and 
you  never  feel  quite  honest  while  you  are  doing  it. 
If  you  want  to  do  favors  to  the  druggist,  such  as 
treating  his  family  gratis,  well  and  good,  but  do  no 
commission  business. 

Be  exceedingly  careful  of  your  early  prescrip- 
tion writing.  The  druggist  invariably  scans  the  in- 
structions of  the  new  doctor  critically,  and  the  laity 

249 


250    BUILDING  A  PROFITABLE  PRACTICE 

as  well  as  the  local  profession  will  soon  learn  of 
the  young  man's  proficiency  or  ignorance,  as  shown 
by  his  prescription.  If  your  first  efforts  at  prescrip- 
tion writing  be  bad,  no  matter  what  your  real  skill 
may  be,  the  druggist  will  classify  you  accordingly, 
the  judgment  will  go  out  quickly,  and  years  of  suc- 
cessful practice  may  not  suflSce  to  eradicate  such  an 
influence. 

Good-natured  cynical  doctors  love  to  disillu- 
sionize the  neophytic  as  to  the  value  of  medicines. 
To  appear  bright  they  will  scoff  at  medicines.  Such 
men  you  will  find  are  either  fools  or  failures.  They 
will  tell  you  that  one  should  tell  the  laity  the  exact 
condition  of  every  ailment,  and  they  will  themselves 
tell  the  laity  that  there  is  no  medicine  for  this  or 
that  disease;  that  scarlet  fever  is  self -limited  and 
needs  no  medication,  etc.  If  you  follow  this  line  of 
talk,  which  is  quite  common  among  recent  hospital 
graduates,  you  will  soon  see  looks  of  distrust  on 
your  patients'  faces  and  often  receive  word  that 
they  have  called  in  their  old  family  doctor.  The 
folly  of  trying  to  explain  the  whole  pathology  of 
disease  in  a  ten-minute  dissertation  to  anyone,  no 
matter  how  intelligent  he  may  be  in  other  things,  is 
very  apparent.  It  took  you  four  years  to  under- 
stand it ;  how  can  another  be  expected  to  learn  it  in 
a  few  minutes? 

Faith  does  a  great  many  things  that  pathological 
process  cannot  explain.  Much  of  the  confidence  of 
the  patient  in  physicians  is  held  together  by  the 
medicine  prescribed.     If  you  tell  them  you  leave 


^^13^"  Jotx^St^  J^LoAJl 


0£J:^^---tkAX&SQJteJ. 


CIS 


^►w;:;. 


Faulty  prescription 


Odd  prescription 


^nM^*rm>   tttlMtrtf 


v^- 


•v 


Careful  prescription 

Practice  of  Pharmacy  (Remington). 

Types  of  prescription  writing. 


Badly  written  prescription 


ON  DRUGS  AND  THE  PHARMACIST      251 

them  to  nature,  nature  gets  the  credit  and  not  your 
genius  in  so  deciding.  Certainly  a  large  proportion 
of  the  poorer  and  middle  class  have  no  confidence  in 
a  doctor  who  does  not  prescribe  medicine. 

From  a  pathological  standpoint  cirrhotic  livers 
and  kidneys,  chronic  lung  and  cardiac  cases  must 
eventually  result  fatally,  yet  they  are  carried  along 
for  many  years  and  eventually  the  patients  die  of 
some  other  disease.  Always  give  some  medicine; 
otherwise,  99  per  cent,  of  your  patients  will  be  dis- 
appointed. Often  your  added  advice  as  to  hygiene, 
etc.,  will  be  far  more  valuable,  but  people  do  not  ap- 
preciate this;  they  want  something  tangible.  Med- 
icine increases  their  faith  in  you.  It  is  good  prac- 
tice to  have  every  patient  on  some  form  of  treat- 
ment; this  is  a  rule  in  most  hospitals.  In  outlining 
treatment  in  any  case  begin  by  regulating  (1)  the 
diet,  (2)  hygienic  measures,  (3)  physical  therapeu- 
tics, (4)  medicines.  Try  to  advise  as  many  thera- 
peutic measures  as  possible  for  the  patient's  com- 
fort in  every  case.  All  of  these  therapeutic  meas- 
ures show  that  you  are  alive  to  the  situation.  It 
keeps  the  family  busy  and  they  appreciate  you  in 
direct  proportion.  If  a  fatal  issue  occurs,  no  one 
can  charge  that  you  did  nothing  for  the  patient. 

Don't  condemn  the  home  treatment  that  was  in- 
stituted before  you  came.  It  is  seldom  of  any  harm 
and  it  may  cause  serious  misunderstandings  in  fam- 
ilies, as  the  one  who  administered  it  will  be  severely 
criticised  and  will  probably  be  your  enemy  after- 
wards. 


252    BUILDING  A  PROFITABLE  PRACTICE 

Don't  order  simples  without  prescribing  tliem 
unless  the  people  are  very  poor.  Remember,  in 
many  cases  natri.  bicarb,  is  much  more  effective 
than  baking  soda,  etc.  This  does  not  apply  to  cases 
where  you  are  giving  other  prescriptions.  Don't 
neglect  to  order  something  for  every  patient  who 
consults  you.  If  there  was  not  something  wrong, 
the  patient  would  not  complain,  and  if  you  don't 
do  something  the  natural-  inference  is  that  you  do 
not  consider  that  there  is  any  cause  for  complaint. 
This  leads  up  to  the  next  point  and  that  is,  never 
to  treat  a  patient's  complaint  with  levity,  no  matter 
how  silly  it  may  seem  to  you;  no  one  really  thinks 
lightly  of  a  doctor's  visit  or  call.  What  you  in  all 
of  your  wisdom  think  is  only  ima^nation  on  the 
part  of  the  patient  is,  after  all,  a  real  symptom. 
So  listen  attentively  to  all  complaints,  weigh  them 
carefully  and  explain  them  away  if  you  think  they 
are  of  no  importance;  but  never  laugh  at  them. 
After  all,  you  are  in  a  measure  the  servant  of  the 
patient ;  he  pays  you  to  listen  to  his  complaints. 

Many  fond  mothers  will  tell  you  that  they  have 
homoeopaths  for  the  children,  because  the  children 
won't  take  the  regular  medicines,  and  sooner  than 
have  none  they  resort  to  the  disciples  of  Hahne- 
mann. Never  neglect  to  advise  that  any  disagree- 
able medicine  should  be  given  in  water.  Pills  are 
not  popular  now;  capsules  and  cachets  are  com- 
monly ordered.  Tablets  are  preferred  by  many. 
The  poorer  classes  have  more  faith  in  medicines  in 
liquid  form  than  in  any  other. 


ON  DRUGS  AND  THE  PHARMACIST      253 

It  is  better  to  give  medicines  in  small  doses  and 
often,  and  use  them  locally  wherever  possible.  The 
patient  may  perhaps  understand  the  process  where- 
by salol  is  split  into  carbolic  and  salicylic  acid  by 
the  alkali  of  the  intestinal  tract  if  you  wish  to  ex- 
plain it  to  him.    It  increases  his  faith  in  the  agent. 

To  infants  give  nothing  that  is  not  pleasant.  If 
you  study  this  matter  you  will  see  that  few  essen- 
tial medicines  are  disagreeable  and  if  properly  ad- 
ministered are  not  very  repugnant. 

Medicine  when  given  to  the  German  is  best  ad- 
ministered in  liquid  form  and  in  fairly  large  quan- 
tity ;  to  French  and  Americans,  the  tablet  or  capsule 
is  preferable  to  the  powder  or  liquid.  Do  not  teach 
the  people  how  to  use  a  hypodermic  syringe  on  them- 
selves. In  fact,  don't  teach  them  self -medication 
any  more  than  you  can  possibly  help.  It  is  unneces- 
sary to  point  out  to  you  the  evil  consequences  upon 
the  patient. 

In  treating  Italians  of  the  poorer  class,  when 
the  patient  is  not  decidedly  improving  daily,  you 
must  daily  change  the  medicine  or  add  some  addi- 
tional medication;  otherwise,  they  are  apt  to  grow 
discontented  and  look  for  a  new  doctor. 

Among  pseudo-scientific  people  there  is  a  grow- 
ing tendency  to-day  for  the  patient  to  read  and  crit- 
icise the  prescription.  If  you  wish  to  prevent  this, 
you  may  substitute  the  Latin  or  Greek  equivalents, 
as,  secale  cornut.  for  ergot,  tr.  thebaica  for  tr.  opii, 
chinin  for  quinine,  or  else  to  use  the  chemical  sub- 
stitute, as  K,  Br,  etc.,  or  you  may  reverse  the  no- 


254    BUILDING  A  PROFITABLE  PRACTICE 

menclature,  as  sulphatis  quin.  instead  of  quinine 
sulph. 

As  a  great  many  people  do  not  have  any  faith 
in  a  colorless  medicine,  in  most  instances  color  it 
with  cudbear.  Chlorophyll  furnishes  a  beautiful 
green  color.  The  proprietary  and  patent  medicine 
people  have  long  been  conscious  of  this  defect  in 
human  nature. 

When  you  prescribe  very  large  doses,  show  the 
druggist  by  an  arrowhead  that  such  is  the  intention. 
In  writing  a  prescription  containing  any  of  the 
opium  or  cocaine  preparations,  you  should  always 
write  **Ne  repetantur"  on  the  prescription.  A 
convenient  way  of  keeping  records  of  your  prescrip- 
tions is  to  have  your  prescription  pads  fitted  with 
carbon  paper  interlining.  This  is  an  excellent  prac- 
tise, as  you  will  then  never  be  kept  awake  all  night, 
worrying  about  the  question  whether  you  wrote  for 
a  3i  or  ^i  of  some  poisonous  drug  in  a  prescription, 
the  dose  of  which  was  a  teaspoonful.  Most  patients 
will  importune  you  for  a  tonic.  Tell  them  that  the 
medicine  that  you  are  giving  them  is  a  tonic,  quali- 
fying that  it  is  a  tonic  for  the  nervous  system,  kid- 
neys, etc.,  as  the  case  may  be. 

If  a  patient  comes  to  you  with  positive  assertion 
that  he  has  such  and  such  a  disease,  don't  be  over- 
anxious to  destroy  the  illusion  unless  you  are  abso- 
lutely certain  that  his  illusion  is  going  to  do  him 
harm.  There  are  plenty  of  people  who  will  have 
their  own  way  in  everything,  and  they  will  have  it 
in  diagnosis  as  well.    You  can  state  that  there  is 


ON  DRUGS  AND  THE  PHARMACIST      855 

some  such  trouble,  but  in  addition,  lie  has  the  dis- 
ease that  you  discover  and  that  you  will  treat  him 
for  both  conditions,  but  most  for  the  disease  diag- 
nosticated by  the  patient.  In  this  way  you  will  not 
injure  his  amour  propre  and  at  the  same  time  will 
do  him  as  much  good  as  though  you  rode  rough  shod 
over  his  opinion ;  in  the  meantime,  you  have  gained 
a  loyal  client. 

Don't  minimize  sprains,  colds,  etc.,  by  saying,  it 
is  only  a  cold,  etc.  Give  it  the  scientific  name  as 
well  as  the  common  name,  if  it  be  a  minor  com- 
plaint, informing  the  patients  that  it  may  cause  a 
bad  result.  If  you  do  not  do  this,  and  as  a  result 
of  infection  they  have  a  stiff  finger,  or  a  lame  arm, 
or  a  general  septicaemia,  you  will  not  be  thanked 
for  your  services. 

OHA.NGINQ  MEDICINES,  ETC. 

At  the  commencement  of  an  illness  it  is  better  to 
write  for  a  2-oz.  mixture  unless  you  are  certain  that 
the  medicine  will  be  of  service  during  its  entire 
course.  Often  the  medicine  will  not  agree  with  the 
patient's  stomach,  and  sometimes  you  will  wish  to 
change  it  the  next  day,  so  that  if  you  order  a  large 
amount  it  will  be  a  constant  reminder  to  the  patient 
and  friends  of  a  slight  error  in  your  judgment, 
aside  from  the  cost  which  ^quite  often  appeals  to 
them  as  forcibly.  In  changing  a  medicine,  do  so 
gradually  unless  there  be  some  digestive  disturb- 
ance following  its  use;  that  is,  continue  it  two  or 


256    BUILDING  A  PROFITABLE  PRACTICE 

three  times  a  day  while  it  lasts,  in  the  meantime 
substituting  the  new  mixture. 

APPABATUS,  ETC. 

Don't  order  expensive  apparatus,  etc.,  unless  you 
cannot  absolutely  get  along  without  it  in  a  prolonged 
case.  In  poor  families  the  $1  for  a  spray  looks  more 
than  the  $1  for  the  doctor.  The  same  applies  to 
belts,  crutches,  etc. 

In  prescribing  expensive  drugs,  tell  the  patient 
beforehand  that  they  are  expensive.  Do  not  be 
anxious  to  try  new  drugs.  Let  the  man  with  a  rep- 
utation take  such  chances. 

THE  DETAHj  man  AND  THE  PBOPREETARIES. 

Many  of  your  early  morning  callers  will  be 
agents  for  various  proprietary  medicines.  Like  the 
early  bird,  they  are  out  to  catch  the  worm.  Listen 
to  their  story,  if  you  have  time,  but  beware  of  such 
advice  as  they  dispense.  They  are  well  drilled  in 
the  story  and  repeat  it  like  a  parrot.  In  spite  of 
the  fact  that  they  often  have  M.D.  attached  to 
their  names,  they  do  not  know  as  much  as  a  first- 
year  medical  student.  Do  not  give  the  sample  that 
they  leave  with  you  to  the  first  patient  that  comes 
along,  because  you  may  perchance  feel  that  it  might 
possibly  help  his  trouble,  inasmuch  as  the  label  so 
promises.  If  you  ever  give  such  samples  to  pa- 
tients, be  sure  to  remove  all  of  the  labels;  other- 
wise, the  patient  will  think  that  you  are  giving  him 


ON  DRUGS  AND  THE  PHARMACIST      257 

patent  medicines.  If  he  feels  better  after  taking  it, 
he  will  take  the  same  bottle  for  the  many  other  dis- 
eases that  the  label  declares  can  be  cured  by  it. 
Meanwhile,  you  will  have  lost  control  of  the  patient. 
Certain  drug  firms  exploit  their  wares  in  this  way. 
They  send  a  large  number  of  small  packages  or 
bottles  of  their  products,  suitably  labeled  of  course, 
and  surrounded  by  instructions  and  advice  to  phy- 
sicians, who  unwittingly  give  them  out  as  samples. 
For  that  reason  proprietaries  containing  magne- 
sium sulphate  are  used  almost  as  much  as  Epsom 
salt,  and  almost  as  many  cures  are  wrought  by  them 
as  by  Epsom  salt,  to  the  great  honor  and  profit  of 
the  manufacturer.  Do  not  allow  yourself  to  be  hum- 
bugged in  this  way.  Don't  be  afraid  of  incompati- 
bilities in  prescriptions.  If  there  is  any  serious  one 
the  druggist  will  notify  you.  If  there  is  anything 
good  in  a  new  article,  the  current  medical  journals 
will  extol  its  merits;  so  don't  prescribe  proprie- 
taries or  patents,  unless  you  are  absolutely  certain 
of  their  superiority.  You  should  consult  with  your 
druggist  as  to  the  best  means  of  disguising  nauseous 
medicines,  and  when  you  have  succeeded  in  disguis- 
ing the  taste  you  have  done  all  that  any  of  the  pro- 
prietaries have  done,  and  done  it  at  half  the  cost  to 
the  patient. 

On  the  other  hand,  prescribe  anything  that  will 
benefit  your  patient,  but  avoid  the  so-called  patent 
medicines,  i.e.,  the  medicines  that  are  advertised  to 
the  laymen.  As  a  matter  of  fact,  they  are  for  the 
most  part  not  patented,  but  are  really  secret  nos- 

17 


268    BUILDING  A  PROFITABLE  PRACTICE 

trums,  not  one  of  which,  so  far  as  I  am  aware,  pos- 
sesses any  value  that  is  not  an  open  book  to  anyone 
who  will  try  to  look  the  matter  up.  There  are  vari- 
ous books  published  containing  a  list  of  the  ingre- 
dients of  these  preparations,  as  well  as  hair  dyes, 
complexion  cream,  etc.  Your  druggist  can  give  you 
a  list  of  such  books;  they  are  styled  formularies. 
The  proprietary  and  really  patented  medicines  do 
not  come  under  that  category.  Many  of  these  are 
elegant  preparations,  and  in  places  where  pharma- 
ceutical skill  is  lacking,  they  are  almost  a  necessity. 
If  you  honestly  believe  that  the  druggist  cannot  put 
up  as  nice  a  preparation,  according  to  the  National 
Formulary  directions,  then  you  are  justified  in  pre- 
scribing the  proprietary. 


CHAPTER  XXXII. 

Building  up  an  Office  Peactice. 

Everyone  should  strive  to  acquire  an  office  prac- 
tice. It  is  the  most  difficult  to  secure  and  possibly 
not  so  remunerative.  On  the  other  hand,  it  is  not 
so  arduous  and  is  more  satisfactory.  It  is  your 
bank  account  against  the  time  when  you  are  ill  or 
too  old  to  get  out.  The  secret  of  acquiring  it  lies 
in  your  ability  to  always  do  something  for  the  pa- 
tient when  he  comes  to  your  office,  that  you  could 
not  do  for  him  at  his  own  home.  A  poor  therapist 
seldom  has  a  large  office  practice.  No  matter 
whether  you  do  any  general  dispensing  or  not,  you 
should  have  a  few  tablets  for  sick  people  who  come 
to  your  office  with  a  severe  headache,  acute  gastric 
disorder  or  constipation.  If  they  are  suffering, 
give  them  then  and  there  something  for  the  relief 
of  the  pain  before  you  have  finished  your  examina- 
tion. Always  aim  to  have  the  patient  feel  better 
after  each  time  he  has  come  to  your  office. 

Whether  you  accomplish  this  by  spraying  his 
nose — and  there  are  plenty  of  people  willing  to  be 
treated  for  years  for  catarrhal  conditions  of  the 
nose  and  throat  by  local  applications  rather  than 
be  cured  at  once  by  operation — or  again  by  reliev- 
ing uterine  disorder  by  tampons;  by  treating  neu- 

259 


260    BUILDING  A  PROFITABLE  PRACTICE 

rasthenics  by  electricity,  rheumatics  by  baking,  vi- 
bration, light,  etc.,  is  a  question  of  your  skill.  All 
of  these  procedures  take  time,  but  as  your  time  is 
your  most  plentiful  asset  in  the  early  years  of  prac- 
tice, do  not  let  that  disturb  you.  Stick  to  your  office 
hours,  and  do  this  from  the  start  of  practice.  Of 
course,  if  you  receive  a  call  in  the  course  of  your 
office  hours,  go  out ;  but  after  you  have  built  up  a 
large  practice,  it  is  well  to  wait,  if  possible,  until 
after  your  office  hours.  If  you  are  not  in  on  two  or 
more  occasions  during  your  office  hours,  a  patient 
is  apt  to  get  the  idea  that  you  are  rarely  at  home. 
Keep  appointments  by  all  means,  as  breaking  them 
discourages  patients. 

STOMACH    CASES. 

Don't  think  that  you  can  relieve  but  the  slightest 
of  stomach  cases  by  a  simple  prescription.  Don't 
mistake  them  for  true  organic  disease,  because  true 
organic  disease  will  often  have  a  neurasthenic 
stomach  engrafted  on  the  primary  condition.  Don't 
tell  these  patients  that  there  is  nothing  the  matter 
with  them.  No  matter  what  the  books  and  patholo- 
gists say,  they  suffer  actually  and  far  more  than 
many  who  have  an  incurable  disease.  Don't  forget 
to  tell  them  to  come  back  if  not  relieved,  and  not  to 
take  more  than  two  bottles  of  the  medicine.  Don't 
call  it  gastritis  or  catarrh  of  the  stomach  unless  you 
are  quite  sure  of  your  diagnosis. 


BUILDING  UP  AN  OFFICE  PRACTICE     261 

NEURASTHENIA. 

In  treating  nervous  women,  suffering  from  neu- 
rasthenia, don't  inform  the  patient  or  friends  that 
there  is  nothing  wrong  with  the  patient,  that  it  is 
only  her  nerves.  They  will  not  believe  that  the,  to 
them,  manifestly  severe  symptoms  that  she  com- 
plains of  are  nothing  but  imagination.  On  the  con- 
trary, assure  them,  as  well  as  the  patient,  that  she 
really  suffers  more  than  tongue  can  tell,  but  that 
the  symptoms  will  surely  pass  of,  and  that  she  will 
surely  get  well.  These  cases  are  very  trying  to  most 
men,  and  if  they  last  long  one  is  very  prone  to 
neglect  them  or  only  visit  them  at  long  intervals. 
Yet,  strangely  enough,  these  are  the  very  ones  that 
will  build  up  a  big  practice  for  you  by  their  constant 
harping  on  their  complaints  and  paying  compliments 
to  your  skill  in  relieving  them.  Treat  the  case  with 
as  much  apparent  seriousness  as  though  it  was  some 
severe  malady.  Call  often,  even  though  it  be  some- 
what repulsive ;  your  presence  does  the  patient  more 
good  than  the  medicine,  which,  by  the  way,  you 
should  always  prescribe.  Confidence  is  engendered 
by  your  presence,  and  people  are  far  more  willing 
to  pay  you  for  your  interest  and  attention  than  you 
think  they  are. 

The  amount  of  serious  illness  is  steadily  dimin- 
ishing; on  the  other  hand,  people  are  paying  more 
attention  to  the  so-called  minor  complaints.  Such 
complaints  a  decade  ago  were  borne  as  a  matter  of 
course,  or  were  treated  by  some  household  remedy. 


262    BUILDING  A  PROFITABLE  PRACTICE 

If  you  wish  to  succeed,  particularly  in  an  oflSce 
practice,  you  must  pay  much  more  attention  to  these 
complaints  than  the  practitioner  of  the  past  has 
done.  Your  text-books  will  not  help  you  much  in 
this  matter;  there  are  a  number  of  small  mono- 
graphs dealing  with  such  matters,  and  the  medical 
journals  have  occasional  articles  on  these  subjects. 


CHAPTER  XXXIII. 

Aids  in  Practice. 

the  treatment  of  children. 

In  the  treatment  of  children  the  physician  is 
called  upon  to  display  all  the  tact,  skill,  and  inge- 
nuity he  possesses.  He  must,  above  all  things,  keep 
his  temper  and  never  get  impatient.  A  child's  con- 
fidence is  difficult  to  get  and  easy  to  lose,  but  once 
it  realizes  that  you  are  its  friend  you  can  have  no 
more  tractable  patient.  There  is  an  old  supersti- 
tion which  many  mothers  believe  in,  to  the  effect 
that  babies  are  perfect  judges  of  character,  and 
while  this  is  a  foolish  belief,  it  is  wise  to  take  ad- 
vantage of  it.  See  that  the  baby  likes  you.  If  you 
can  win  the  baby's  affection,  the  entire  family  is  at 
your  disposal.  The  first  five  years  of  a  baby's  life 
is  the  period  of  most  financial  benefit  to  the  doctor. 

HABITS. 

All  of  your  after  success  depends  on  the  habits 
you  acquire  in  the  first  year  or  so  of  your  practice. 
You  will  scarcely  change  much  after  your  second 
year.  Try  to  cultivate  cheerfulness,  industry,  hap- 
piness, punctuality,  and  honesty.  As  the  bough  is 
bent,  so  the  tree  inclines.  Punctuality  is  easily  ac- 
quired and  as  easily  lost.  Go  to  bed  no  later  than 
eleven  and  rise  no  later  than  eight.  Most  young 
practitioners  think  that  they  might  as  well  sleep  on 
as  long  as  there  are  no  patients  waiting  for  them. 

263 


264    BUILDING  A  PROFITABLE  PRACTICE 

It  is  not  likely  to  improve  a  patient's  opinion  of 
you  for  him  to  find  you  in  bed  at  nine  or  ten  in  the 
morning,  when  others  have  already  half  a  day's 
work  done.  It  is  not  at  all  infrequent  to  see 
patients  who  have  gone  around  in  the  morning  from 
one  doctor  to  another,  until  they  find  one  who  is  up 
and  about — of  course,  he  gets  the  case.  If  the 
shades  are  up,  people  will  often  come  in  on  their 
way  to  work,  when  they  would  otherwise  pass  by, 
thinking  that  you  are  not  awake  yet. 

DIET  SLIPS. 

Printed  diet  slips  for  half  dozen  of  the  principal 
diseases  that  require  careful  dieting,  such  as  dia- 
betes, the  various  stomach  disorders,  nephritis,  etc., 
are  very  useful  adjuncts.  They  afford  patients 
something  definite  in  the  line  of  regulating  their 
diet,  and  show  that  you  take  an  interest  in  that  par- 
ticular disease,  that  you  have  treated  many  such 
cases  and  are  up-to-date  on  the  subject.  Further- 
more, it  is  a  legitimate  way  of  advertising  yourself. 
Every  time  a  patient,  or  any  one  else,  for  that  mat- 
ter, looks  at  the  diet  sheet  your  name  is  in  e\4dence, 
and  it  serves  to  remind  him  of  his  return  call  to 
your  oflSce.  The  card  should  be  of  stiff  cardboard 
and  should  read  somewhat  as  follows: 

SPECIAL    (STOMACH)    CASE. 
Diet  Cabd  fob  Present  Condition  of 


Db.. 


AIDS  IN  PRACTICE 


265 


MAY   HAVE 

Chopped  Steak  (2) 
Mutton  Chop   (2) 
Chicken  (1/4) 
Roast  Beef  (1) 
Boiled  Ham 
Butter 
Smelts 
Boiled  Fish 
Oysters,  Raw 

Milk  and  Cream 

Eggs,  Soft  Boiled  or  Poached  (2) 

Toast,  Stale  Bread   (3) 

Zwieback 

Well  Cooked  Cereals 

Cream  of  Wheat 

Farina 

Green  Peas 

Baked  Potatoes 

Stewed  Prunes 
Vichy  T 
Cocoa 


MUST  NOT  TAKE 

Pork,  Veal,  Corned  Beef 
Smoked  Meats 
Sausage,  Goose,  Duck 
Bacon,  Fried  Ham 
Cheese,  No  Soups 
very  little  Salt,  Salmon 
Mackerel 

Shad,  Herring,  Clams 
Fried  Fish,  Ice  Cream 
and  Soda,  Fried  Eggs 
Fresh  Breads,  Rolls 
Salads  of  all  kinds 

Fried  Potatoes,  Sweet 

Potatoes,  Cabbage 

Carrots 

Lima  or  Soup  Beans 

Cakes,  Pastries,  Pies, 
Pudding,    Raw   Fruit 
Nuts,  Radishes,  Pepper 
Vinegar,  Cold  Meats 
Tea,  Coffee 


In  default  of  this,  you  may  use  the  diet  slip  fur- 
nished by  drug  firms,  always  erasing  the  names  of 
the  donors,  so  that  it  does  not  look  like  a  patent 
medicine  advertisement  to  the  patient.  Such  slips 
are  seldom  correct,  and  not  very  satisfactory. 


INTEREST  IN  THE  ORDINARY  CASE. 

In  your  dispensary  and  private  work,  strive  to 
be  interested  in  the  common  ordinary  case.  Don't 
devote  all  of  your  time  looking  for  the  rare  cases. 


266    BUILDING  A  PROFITABLE  PRACTICE 

From  a  practical  standpoint,  your  success  in  life 
depends  on  your  treatment  and  management  of  the 
ordinary  case.  A  case  of  pulmonary  tuberculosis 
or  a  neurasthenic  stomach  may,  after  a  few  months 
of  dispensary  work,  seem  too  ordinary  for  you  to 
devote  more  than  a  passing  moment's  attention;  yet 
there  is  more  of  practical  value  to  be  learned  from 
every  such  case  than  from  the  rarest  case  of  acro- 
megaly, Addison  disease,  or  what  not.  These  com- 
mon cases  are  the  ones  that  you  will  see  daily,  and 
your  skill  m  handling  them  will  determine  your  fu- 
ture success.  As  common  as  they  are,  no  one  knows 
how  to  handle  all  of  them  or  any  large  percentage 
of  them,  and  you  cannot  study  them  too  much. 
There  is  no  such  thing  as  standing  still  and  letting 
the  practice  grow.  One  must  be  continually  making 
new  circles — either  by  acquaintance  or  by  demon- 
strating skill  in  certain  lines,  by  new  instruments, 
by  new  procedures ;  otherwise,  practice  will  be  grad- 
ually curtailed.  Old  men  who  fail  to  take  this 
principle  into  account  usually  lose  their  hold.  Some 
of  them  complain,  but  few  seem  aware  of  the  true 
cause. 

It  is  sometimes  advisable  to  stay  up  with  the 
dying  patient,  especially  in  good  families.  It  will 
be  gratefully  remembered,  and  in  some  cases  will 
prevent  their  sending  for  another  doctor,  who  may 
be  piratical  enough  to  say  harsh  things  concerning 
you,  and,  strangely  enough,  people  almost  always 
believe  the  last  man's  word  and  verdict  on  any  case. 


AIDS  IN  PRACTICE  «67 

SEXUAL   DISCUSSION. 

Most  young  physicians  feel  timid  in  discussing 
sexual  problems  with  their  patients.  It  is  wise  not 
to  seek  such  conversations,  but  you  must  not  shirk 
your  duty.  In  speaking  of  the  genitals  use  the  term 
"privates";  it  will  be  more  intelligible;  copulation 
in  the  case  of  married  people  is  best  spoken  of  as 
"family  relations";  sometimes  the  term  "connec- 
tion" is  used.  In  trying  to  find  out  if  a  young  girl 
has  ceased  menstruating  as  a  result  of  pregnancy, 
you  can  often  get  her  rather  timid  answer  by  ques- 
tioning, if  she  is  keeping  company  with  anyone.  If 
she  hangs  her  head  and  says  "Yes,"  your  sus- 
picions may  be  aroused. 

In  all  of  your  sexual  examinations  or  question- 
ing, be  serious  and  businesslike;  never  joke,  be- 
cause it  will  be  misunderstood. 

ACCIDENT  ADJUSTEES. 

Don't  commit  yourself  to  adjusters  for  accident 
insurance  cases,  who  come  to  you  presumably  to 
settle  a  case.  They  are  very  often  wolves  in  sheeps' 
clothing,  and  will  often  try  to  get  a  statement  from 
you  that  may  imperil  the  claim  of  your  patient. 
Absolutely  refuse  to  discuss  the  case  with  them 
unless  there  is  a  settlement  pending,  when  you  can 
put  the  case  as  strong  as  honesty  will  permit.  It  is 
generally  better  for  a  physician  not  to  try  to  ar- 
range any  settlement,  as  in  any  event  he  will  be 
criticised.  Some  one  will  tell  the  patient  that  he 
should  have  received  far  more,  and  many  will  think 
that  you  are  making  a  fat  fee  from  the  company. 


CHAPTER  XXXIV. 
On  Making  Emends. 

As  soon  as  you  have  settled,  go  out  and  make  the 
acquaintance  of  the  nearby  druggists.  They  will 
generally  tell  you  of  the  great  financial  success  of 
the  nearby  doctor.  Listen  to  all  they  have  to  tell 
you,  but  do  not  criticise  any  doctor.  If  gracious, 
they  will  send  you  accident  and  emergency  cases. 
Unfortunately,  most  druggists  will  send  them  to  the 
men  with  the  largest  practice.  However,  if  you 
step  into  the  store  often,  you  will  be  apt  to  get  an 
odd  case.  When  a  druggist  calls  you  up  relative  to 
a  prescription  always  thank  him,  as  he  stands  as  a 
protection  against  any  indiscretion  or  errors  in  your 
prescription  writing.  You  will  also  become  more 
familiar  with  the  appearance  and  use  of  drugs,  if 
you  frequent  the  dispensing  room  of  a  druggist. 

If  you  belong  to  any  religious  body,  go  to  church 
regularly  and  be  seen  there,  not  as  an  advertise- 
ment, but  it  will  make  people  know  that  you  have 
some  fixed  moral  and  religious  principles  that  agree 
with  their  own,  whatever  they  may  be.  But  do  not 
try  to  make  capital  out  of  it;  it  will  antagonize 
others,  both  physician  and  layman.  Sunday-school 
teaching,  gospel  leading  and  addressing,  etc.,  should 
all  be  tabooed.  No  matter  what  your  religion  may 
be,  never  be  a  bigot.    Don't  laugh  or  sneer  at  any 

268 


ON  MAKING  FRIENDS  269 

religious  or  political  faith;  one  man's  opinion  is  as 
good  as  another.  Eemember,  you  must  know  no 
creed  or  politics — all  men  are  alike  to  you,  and  no 
matter  what  they  may  say  or  think  of  religion,  make 
no  comment. 

In  the  city,  the  friendship  of  janitors  is  not  to  be 
despised.  Good  souls  that  many  of  them  are,  they 
are  the  impromptu  nurses  of  the  poor,  and  even  of 
the  moderately  well-to-do.  You  will  find  them,  as 
a  rule,  fairly  intelligent.  Treat  them  at  half  rates 
and  tell  them  so;  often  charge  them  nothing.  A 
hustling  janitor  will  get  you  more  patients  than  a 
clergjmian,  and  they  will  usually  be  able  to  tell  you 
if  the  people  will  pay  you. 

Treat  nurses  and  the  women  about  the  sick  room 
with  politeness  and  consideration.  If  you  make 
friends  with  these  old  women,  they  will  cover  up 
your  many  blunders  and  will  do  much  to  insure  your 
continuance  in  cases  from  which  you  would  be  other- 
wise dismissed.  Likewise,  they  will  try  to  send  you 
patients.  For  the  most  part  they  are  barely  able 
to  eke  out  an  existence.  Charge  them  a  minimum 
fee,  or  not  at  all.  Trained  nurses  are  usually  able 
to  pay  full  fees. 

Be  serious  always.  Membership  in  secret  socie- 
ties, lodges,  etc.,  is  of  benefit  in  making  a  man 
known,  provided  that  the  members  are  of  the  proper 
kind.  Some  physicians  are  very  successful  in  mak- 
ing friends  in  such  societies,  other  men  are  by  na- 
ture diffident  and  backward  and  reap  no  benefit  from 
them.    In  any  event,  to  get  anything  out  of  them  it 


«70    BUILDING  A  PROFITABLE  PRACTICE 

is  necessary  to  attend  the  meetings  regularly  and 
meet  the  members  early  and  often. 

It  is  worth  while  to  cultivate  the  friendship  of 
men  who  are  in  semi-public  positions,  and  who  come 
in  contact  with  large  numbers  of  people  residing  in 
your  neighborhood.  Hotel  clerks,  bartenders,  etc., 
may  well  be  shown  favors  in  rendering  bills  if  they 
go  out  of  their  way  to  send  you  patients.  Of  course, 
you  should  let  them  know  that  you  are  making  con- 
cessions in  this  way.  It  is  certainly  good  ethics  to 
return  a  favor,  whether  it  be  in  medicine  or  in  any 
other  profession.  Of  course,  you  would  not  hang 
around  hotels,  etc.,  under  any  circumstances  what- 
soever unless  you  were  the  hotel  physician. 

Avoid  making  enemies.  In  other  professions 
enemies  are  not  of  so  much  consequence  in  inter- 
fering with  success;  with  you  such  enemies  may 
ruin  you  in  your  early  years,  and  you  must  do  every- 
thing to  disarm  unfavorable  criticism,  even  though 
it  wounds  your  own  self-pride  in  so  doing.  That 
can  easily  be  smothered  when  you  consider  that  the 
time  will  surely  come  when  you  can  be  independent 
and  not  beholden  to  anyone.  Anyone  who  suc- 
ceeds in  avoiding  enmities  is  bound  to  succeed  in 
practice;  while  it  is  doubtless  true  that  men  who 
make  strong  enemies  will  also  make  strong  friends, 
it  does  not  help  to  the  same  extent  in  medicine  as 
elsewhere.  Implacable  enemies  are  a  continual 
yeast,  breeding  mischief  for  your  future  practice. 


CHAPTER  XXXV. 

Pebsonal  Mannebs. 

Try  to  cultivate  a  pleasing  manner  towards  peo- 
ple, particularly  towards  the  women  and  children 
that  you  meet  in  the  street.  If  you  are  stern  and 
pass  acquaintances  without  a  bow  or  smile,  you 
will  drive  away  many  a  prospective  patient. 

Let  cleanliness  in  all  things  be  your  motto,  and 
let  patients  see  that  that  is  your  watchword,  whether 
it  be  the  invariable  washing  of  the  thermometer,  the 
cleansing  of  your  hands  after  attention  to  the  sick, 
the  cleanliness  of  your  clothes,  or  just  as  important, 
the  cleanliness  of  your  language.  Let  it  be  ever 
evident;  no  joking,  no  risque  stories,  smoking  sel- 
dom, and  chewing  tobacco  never. 

In  dealing  with  patients,  who  are  also  friends 
and  relatives,  treat  them  the  same  as  strangers; 
when  they  are  consulting  you  be  all  business  and 
no  gossip.  It  is  better  to  take  money  from  them, 
if  they  offer  it,  as  they  will  feel  more  independent. 
Never  be  disappointed  if  your  relatives  or  friends 
do  not  consult  you,  no  matter  how  smart  you  think 
you  are.  There  is  nothing  so  dear  as  one's  own 
body,  and  you  cannot  blame  people  for  having  what 
they  think  is  the  best  for  themselves  in  this  regard. 
Don't  fail  to  explain  that  to  them.  Besides,  there 
are  many  personal  reasons  in  families  of  your  rela- 

271 


«72    BUILDING  A  PROFITABLE  PRACTICE 

tives  and  friends  that  make  them  hesitate  to  confess 
their  sins  or  weaknesses  to  you. 

Don't  deceive  anyone,  even  a  child.  When  you 
are  going  to  hurt  anyone,  tell  them  that  it  will  hurt 
a  little ;  but  never  suddenly  open  an  abscess,  or  sew 
a  wound  without  telling  the  patient  that  you  must 
do  so.  If  you  do,  the  patient  will  never  have  any 
confidence  in  you  again.  If  he  says,  you  must  not  do 
so  and  so,  and  if  he  is  not  a  small  child,  do  not  do  it 
whatever  the  operation  may  be,  as  you  have  no  legal 
right  to  do  so.  Then  say  you  will  do  the  next  best 
thing,  etc.,  but  don't  show  your  disgust  when  pa- 
tients do  not  want  things  done  as  you  feel  they 
should  be.  If  you  do,  they  will  go  to  Dr.  Jones, 
who  may  do  even  as  you  do  and  yet  they  will  event- 
ually let  him  do  the  very  operation  you  essayed,  or 
he  may  temporize  as  you  should,  and  keep  them  ever 
afterward  as  patients. 

Let  your  associates  be  few,  and  never  become 
confidential  with  a  layman.  Much  of  the  distrust  of 
the  profession  to-day  arises  from  such  confidences 
made  in  an  offhand  way  to  laymen.  The  young  doc- 
tor confidently  states  that  there  is  no  absolute  cure 
for  but  two  or  three  diseases;  that  medicines  do 
little  good,  etc.  These  statements  are  only  relatively 
true,  and  are  only  meant  in  a  relative  manner;  not 
so  the  layman.  He  takes  them  seriously  and  be- 
lieves that  neither  you  nor  any  other  M.D.  knows 
anything,  and  hies  himself  to  the  science  healer,  the 
osteopath,  or  what  not.  It  is  better  to  have  your 
friends  and  associates  among  the  members  of  your 


PERSONAL  MANNERS  273 

own  profession.  You  will  always  be  learning  some- 
thing from  them,  and  it  is  only  among  your  peers 
and  equals  that  you  can  feel  at  home. 

Always  seem  serious  and  busy  when  patients 
come  into  your  oflSce;  have  medical  books  and  jour- 
nals strewn  about,  showing  that  you  are  studying. 
Never  let  patients  see  you  reading  novels,  or  other 
light  literature;  you  must  ever  and  always  appear 
a  serious  worker  in  a  serious  business. 

Aim  to  get  a  reputation  for  carefulness,  above 
all  things.  Thorough  examination  and  carefulness 
are  synonymous  terms.  Show  that  you  value  human 
life  above  all  things.  Genius  counts  for  little  in 
successful  practice.  Likewise,  fine  diagnostic  abil- 
ity is  not  nearly  so  often  appreciated  as  the  relief 
of  symptoms  and  confidence  that  nothing  is  over- 
looked. 

Regard  every  case,  no  matter  how  trivial,  with 
all  possible  interest;  remember  there  is  in  the  whole 
world  no  other  case  exactly  similar.  Patients  like 
to  have  one  take  an  especial  interest  in  them.  Many 
of  these  cases,  that  to  you  in  your  earlier  days  seem 
wonderful,  will  look  commonplace  later.  Yet  your 
patient  and  his  friends  will  probably  be  your  faith- 
ful supporters  for  many  years  afterward.  Most 
people  like  a  lot  of  attention ;  like  to  have  the  doctor 
examine  them  from  head  to  toe  at  each  visit;  like 
him  to  apply  treatment  if  possible  himself ;  if  there 
is  a  mustard  plaster  to  be  made,  that  he  should  su- 
perintend its  making  and  put  it  on  himself,  to  give 
medicine  himself,  etc. 

18 


CHAPTER  XXXVI. 

Personal,  Appeabance. 

Avoid  prominence  in  baseball  games,  races,  etc. 

A  distinctive  style  of  dress  is  often  of  value.  It 
will  attract  some  attention.  This  is  entirely  a  mat- 
ter of  taste.  Try  to  look  like  a  doctor.  This  may 
seem  indefinite,  but  it  is  not  very  hard  to  acquire  the 
appearance,  so  that  strangers  will  pick  you  out  as 
a  doctor,  or  at  least  as  a  professional  man.  The 
doctor  in  the  minds  of  most  city  dwellers  to-day  is 
tall  and  thin  and  wears  a  Van  Dyke  beard,  or  at 
least  approaches  this  style.  He  may  have  a  full 
beard  or  not,  but  he  should  be  easily  recognized  as 
a  professional  man. 

Unless  you  are  practising  in  your  home  town, 
people  do  not  know  how  old  you  are;  they  judge 
your  experience  to  be  commensurate  with  your  age, 
or  how  old  you  look.  They  will  not  question  you 
how  many  years  you  spent  in  practice,  or  how  many 
hospitals  you  attended,  but  if  you  look  old  enough, 
they  think  that  you  know  at  least  as  much  as  the 
average  physician.  This  is  one  reason  that  men, 
entering  medicine  comparatively  late  in  life,  get 
along  faster  in  practice  than  the  younger  man,  yet 
the  minds  of  the  latter  are  really  more  mobile  and 
retentive,  and  they  are  generally  better  posted  than 
the  older  man ;  but  the  layman  does  not  view  it  that 
way. 

Don't  chew  tobacco,  and  don't  go  to  your  pa- 

274 


1»ERS0NAL  APPEARANCE       276 

tients  smelling  strongly  of  tobacco  in  any  form — to 
the  well  it  may  not  seem  repulsive,  to  the  sick  it  may 
be,  and  often  is  loathsome.  The  same  thing  holds 
good,  only  in  a  greater  degree,  with  regard  to  alco- 
hol on  the  breath  of  a  doctor,  which  condemns  him 
in  the  eyes  of  very  many  people. 

A  neat,  well-dressed  man  has  advantage  over  a 
slovenly  one.  A  prominent  employer  said :  '  ^  If  you 
have  $25  and  want  a  position,  it  is  better  to  spend 
$20  for  clothes,  $4  for  shoes,  and  the  rest  for  a  shine 
and  hair-cut,  collar,  and  walk  to  the  place,  than  ride 
with  the  money  in  the  pocket  of  a  slovenly  suit." 

Good  clothes  and  neat  appearance  will  get  you 
many  a  good  patient.  Unfortunately,  many  doctors, 
particularly  in  the  country,  fall  into  slovenly  habits 
especially  as  to  their  clothes;  this  militates  against 
them.  Clean  polished  shoes,  well  groomed  hair, 
neat,  clean  clothes,  collars,  cuffs,  and  neckties  are 
not  expensive.  Cleanliness  is  a  virtue,  and  filthi- 
ness,  either  in  character  or  in  clothes,  is  to  be  ab- 
horred. Sick  people  are  close  observers,  and  the 
least  bit  of  vulgarity  is  repulsive.  The  story  is  told 
of  a  Boston  lady,  who  refused  to  see  a  physician  the 
second  time  because  he  said  broncheetis  instead  of 
bronchitis. 

If  one  can  master  a  prepossessing  appearance, 
social  introductions  are  likely  to  help  him  to  a 
practice. 

The  layman,  on  meeting  you  for  the  first  time, 
almost  always  makes  a  mental  estimate  of  your 
ability.    On  such  an  introduction  he  has  no  facts  on 


276    BUILDING  A  PROFITABLE  PRACTICE 

which  to  base  a  judgment,  but  that  does  not  matter. 
At  once  he  imagines  himself  your  patient  and  pict- 
ures you  according  to  your  physico-mental  appear- 
ance. If  he  is  finical  as  to  dress,  he  weighs  you 
correspondingly.  If  he  is  a  believer  that  good  looks, 
elegant  physique,  etc.,  are  accompaniments  of  a  fine 
mind,  you  will  be  judged  so  far  as  you  meet  these 
requirements.  Women,  even  more  than  men,  are 
affected  by  such  externals. 

A  beard  is  of  value,  in  that  it  covers  your  youth- 
ful appearance;  it  prevents  people  from  properly 
estimating  your  age.  While  it  is  true  that  the  ideal 
physician,  as  he  exists  in  the  mind  of  the  layman, 
is  not  an  aged  patriarch,  as  he  was  pictured  a  few 
decades  ago,  still  a  too  verdant  appearance  does  not 
speak  for  much  experience. 

If  you  have  these  personal  charms,  by  all  means 
use  them  as  a  means  of  enlarging  your  practice.  If, 
on  the  other  hand,  you  lack  them,  do  as  Cicero  ad- 
vises with  wealth:  despise  them  and  avoid  society 
as  such.  In  any  case,  strive  by  study  to  perfect 
yourself  so  that  eventually  reputation  for  good  work 
— which  is  the  only  lasting  reputation — will  drive 
people  to  you. 

Do  not  have  yourself  purposely  called  out  in  the 
midst  of  a  meeting  or  sermon,  just  to  show  that  you 
are  busy.  Do  not  become  prominent  in  public  meet- 
ings, else  people  will  think  that  you  devote  most  of 
your  time  to  such  things  and  neglect  your  practice. 
All  patients  are  jealous.  They  don't  care  anything 
about  your  prominence,  your  diamonds,  your  speech- 
making,  your  wife,  etc.;  they  want  you  to  devote 


B*^-"^'^*"" 


Playthings — an  aid  in  the  office  when  examining  young  children. 


PERSONAL  APPEARANCE  «77 

your  entire  time  to  them  when  consulting  you.  For 
that  reason  a  joking  physician  is  seldom  successful. 
Don't  be  unduly  familiar  with  clergymen.  Other 
physicians  and  laymen  are  apt  to  ascribe  wrong  mo- 
tives on  your  part;  at  any  rate,  do  not  allow  them 
to  take  you  around  and  introduce  you  among  the 
people  who  are  already  the  patients  of  other  physi- 
cians. I  have  seen  this  simple  procedure  practically 
ruin  the  career  of  a  very  bright  man  because  of  pro- 
fessional jealousy  resulting  therefrom. 

People  will  employ  you,  mostly  because  some  one 
else  has  spoken  of  you.  The  more  that  speak  well 
of  you  in  any  way,  the  better  for  yourself. 

Under  no  condition  accept  alcohol  in  any  form 
from  a  patient.  The  very  same  people  will  be  the 
first  to  say  that  you  drink  to  excess  or  will  be  very 
ready  to  believe  that  you  do  so  if  some  one  else  says 
so.  It  is  better  not  to  accept  cigars  or  other  pres- 
ents, as  people  always  expect  a  quid  pro  quo — do 
everything  on  a  business  basis — pay  for  what  you 
receive  and  likewise  expect  the  same  treatment  from 
others. 

It  is,  of  course,  but  proper  that  you  patronize  the 
stores  in  your  immediate  neighborhood,  even  though 
it  cost  you  more  than  elsewhere,  and  have  them 
send  goods  in  your  own  name,  that  they  may  possi- 
bly think  of  you  when  some  one  is  ill.  They  may  not 
quite  feel  like  trusting  you  for  themselves  as  in  pref- 
erence to  the  family  doctor,  but  they  will  be  likely 
to  speak  well  of  you  to  others.  Do  not  quarrel  with 
them,  if  their  wares  do  not  suit  you,  but  quietly 
go  elsewhere. 


CHAPTER  XXXVn. 

Marriage. 

Most  young  men  are  apt  to  smile  at  the  mention 
of  marriage,  but  the  old  saying  is  that  doctors  and 
ministers  must  be  married.  In  this  matter,  two 
courses  are  open  to  you.  If  you  intend  to  do  scien- 
tific work,  to  make  a  great  name  for  yourself,  not  to 
acquire  a  practice,  put  off  marriage  until  you  have 
your  work  well  in  hand.  No  man  can  serve  two 
mistresses — Science  and  Home.  If,  on  the  other 
hand,  you  are  going  to  practise  medicine,  as  most 
of  you  will,  you  must  soon  begin  to  think  of  mar- 
riage as  a  reality.  In  the  large  cities  an  unmarried 
physician  is  not  to-day  at  much  disadvantage.  In 
the  country  and  smaller  cities,  however,  people  have 
such  a  sense  of  modesty  that  single  blessedness  is  a 
great  drawback.  Don't  get  married  for  a  year  or 
two,  and  not  then  unless  you  can  support  a  wife  at 
once.  The  right  kind  of  a  woman  is  willing  to  start 
with  little.  Most  people,  especially  women,  have  a 
notion  that  a  doctor  is  a  veritable  gold  mine.  Be- 
ware of  marrying  any  young  frivolous  school  girl 
with  poetic  aspirations;  rather  marry  one  who  will 
be  able  to  do  her  own  housework  for  a  few  years. 
Trained  nurses  make  good  doctors'  wives.  He  who 
marries  money  often  earns  it.  Beware  of  a  jealous 
person  in  the  shape  of  a  wife.  I  have  known  many 
physicians  whose  minds  were  upset  and  whose  prac- 
tices were  lost  through  unreasonable  jealousy  on  the 

«78 


MARRIAGE  279 

part  of  the  wife.  Don't  allow  your  wife,  or  anybody 
else,  to  come  unannounced  into  the  office  during  a 
consultation.  Don't  have  the  door  open,  so  she  can 
hear.  Bring  her  up  not  to  do  such  things.  Many 
women  patients  are  exceedingly  timid  in  telling 
their  troubles  if  they  have  the  least  fear  that  anyone 
else  is  listening  to  their  stories.  For  this  reason, 
be  careful  in  closing  folding  doors  between  your 
office  and  reception  room. 

Don't  discuss  your  cases  or  medicines  at  your 
own  table,  as  it  makes  hypochondriacs  of  your  own 
family.  You  will  doubtless  be  quizzed  innocently  by 
your  women  folk  as  to  what  is  the  matter  with  So- 
and-So.  All  such  quizzing  leaks  out,  and  owing  to 
the  position  that  your  wife  holds  in  the  community, 
her  statements  have  greater  weight  for  evil  than  if 
said  by  another.  Regard  everything  that  takes 
place  in  your  office  as  a  confessional  secret. 

If  you  begin  to  tell  her  the  many  eccentricities 
and  foolish  flatteries  of  your  female  patients,  she 
will  naturally  suspect  you.  She  should  be  interested 
in  your  work,  and  if  she  can  aid  you  through  her 
friends,  will  do  so.  I  know  many  physicians  who 
owe  the  major  part  of  their  practice  to  the  influence, 
socially,  of  the  wives.  A  doctor's  wife  is  in  a  dif- 
ferent position  from  that  of  any  other  professional 
man;  she  is  a  partner  in  the  business;  she  must 
know  in  a  general  way  about  his  finances,  what  pa- 
tients are  good  pay,  and  those  whom  he  can  do  with- 
out. She  must  use  her  judgment  in  taking  care  of 
his  practice  when  he  is  not  at  home,  and  be  anxious 
and  ready  to  find  him  when  necessary. 


CHAPTER  XXXVIII. 

Don'ts  in  Practice. 

investments. 

Don't  invest  your  little  savings  in  any  wildcat 
schemes,  mine  stocks  or  the  like.  The  schemers  and 
mine  operators,  stock  brokers,  etc.,  regard  medical 
men  as  the  easiest  prey,  as  they  are  in  a  sense  more 
imaginative  than  those  engaged  in  other  occupa- 
tions, and  consequently  prospective  schemes  appeal 
more  to  them.  You  will  find  your  mail  littered  with 
such  prospectuses,  etc.;  pay  no  attention  to  any- 
thing that  promises  great  returns,  and  don't  let  any 
patient  try  to  make  money  for  you  by  getting  you 
in  on  the  inside — as  a  favor  for  your  valuable  serv- 
ices. This  last  is  an  old  trick,  often  played  in  an 
apparently  unintentional  manner.  Invest  your  sav- 
ings in  real  estate,  mortgages  or  reliable  bonds  and 
stocks,  but  don't  do  any  gambling  on  margin;  very 
many  doctors  think  that  they  can  beat  the  market. 
It  is  doubtful  if  one  in  a  hundred  do  more  than  come 
out  even. 

HEALTH    AND    ACCIDENT    INSURANCE. 

A  health  and  accident  policy,  costing  from  thirty- 
five  to  sixty  dollars  a  year,  may  seem  a  little  ex- 
pensive, but  in  view  of  the  very  great  exposure  that 
one  in  our  profession  is  subject  to  from  inclement 

280 


DON'TS  IN  PRACTICE  281 

weather,  from  injuries  in  travelling,  as  well  as  the 
thousand  and  one  infections,  it  is  a  good  annual  in- 
vestment. Such  policies  pay  at  the  rate  of  twenty- 
five  dollars  a  week,  or  portion  of  a  week,  for  com- 
plete disability,  and  proportional  for  partial  dis- 
ability. It  is  quite  a  comfort  to  know  that  your  rent 
will  be  paid,  no  matter  how  long  you  are  ill. 

Such  a  policy  is  of  far  more  value  to  the  young 
man  than  straight  life  insurance,  because  you  need 
the  money  now,  and  have  no  one  else  dependent  on 
you.  A  physical  examination  is  not  demanded.  Buy 
such  a  policy  from  an  old-established  company,  and 
above  all,  see  that  the  agent  is  a  reliable  man.  The 
companies  are  as  a  rule  quite  liberal  in  their  inter- 
pretations of  such  policies  if  the  facts  are  placed 
honestly  before  them. 

RELIGIOUS  BELIEFS. 

In  orthodox  Jewish  families  the  use  of  pork  fat 
or  soap  made  therefrom  is  an  abomination.  Use 
vaseline  instead  of  lard  as  lubricant  for  the  ther- 
mometer, and  as  a  base  for  ointments. 

In  Catholic  families  do  not  insist  on  the  patient 
eating  meat  on  Friday ;  on  other  fast  days,  the  rule 
forbidding  meat  is  not  so  strictly  observed. 

The  scapular  is  worn  about  the  neck  of  most 
Roman  Catholics.  It  usually  consists  of  two  pieces 
of  cloth  with  a  picture  on  each — ^the  insignia  of 
an  Order  or  Society,  in  a  measure  similar  to  any 
other  society.  Furthermore,  it  is  believed  that,  in- 
asmuch as  the  Patron  of  the  Order  is  a  celestial  be- 


282    BUILDING  A  PROFITABLE  PRACTICE 

ing,  its  wearing  will  serve  ta  protect  the  wearer 
from  harm.  Likewise,  a  cord  is  worn  about  the 
waist  by  some  people  with  much  the  same  intent  and 
purpose.  Don't  ruthlessly  tear  these  off  and  sneer 
at  them,  as  it  hurts  the  sensibilities  of  the  wearer 
more  than  he  will  show  by  any  external  signs. 

Cultivate  the  child.  If  possible,  take  the  temper- 
ature in  the  axilla  unless  it  is  absolutely  necessary 
to  take  it  in  the  rectum.  I  have  seen  a  spoon  on 
which  sugar  was  sprinkled,  relished  as  a  tongue 
depressor,  where  it  was  almost  impossible  to  see 
the  throat  with  a  plain  spoon. 

Don't  tell  a  wife  that  she  has  contracted  gon- 
orrhoea or  syphilis  from  her  husband,  and  certainly 
you  should  not  tell  a  husband  that  he  contracted 
either  of  these  diseases  from  his  wife,  as  not  rarely 
happens.  You  may  ascribe  the  infection  to  closet, 
toilet  paper,  etc.  Many  homes  have  been  broken 
up  by  injudicious  truth  telling  in  such  matters;  no 
possible  good  can  come  from  such  candor.  You  are 
not  the  censor  of  the  morals  of  your  patients.  When 
a  man  comes  to  you  and  says  that  he  contracted  gon- 
orrhoea from  a  closet,  there  is  no  use  in  disabusing 
his  intention  to  deceive  you,  and  he  will  not  be 
ashamed  to  meet  you  afterward,  as  he  may  when  he 
knows  that  you  know  him  to  be  a  sinner.  For  this 
reason,  the  family  doctor  is  seldom  consulted  by 
youths  suffering  from  venereal  disease. 

Family  jars,  between  man  and  wife  or  children 
or  relatives,  are  aften  poured  into  your  ears.  Lis- 
ten attentively,  but  avoid  saying  anything  tangible. 


DON'TS  IN  PRACTICE  283 

You  may  appear  sympathetic,  saying,  that  is  ''really 
too  bad,"  or  "is  that  sol"  but  be  careful  never  to 
give  any  advice  as  to  separation,  the  infliction  of 
any  punishment,  or  strenuous  advice  of  any  kind. 
Blood  is  thicker  than  water,  and  no  matter  how  deep 
the  wound  may  be,  matters  will  sooner  or  later  be 
patched  up  and  you  will  find  yourself  the  loser.  The 
one  party  will  hate  and  fear  you,  and  the  other  will 
be  ashamed;  you  will  constantly  be  quoted  as  ad- 
vising severe  punishment  or  calling  him  or  her  such 
a  name,  whether  you  did  or  not. 

PREACHING   MORALS. 

You  will  often  be  asked  to  preach  morals  to 
some  one  who  is  either  a  drunkard  or  worse,  or 
perhaps  you  will  feel  like  scolding  him.  Experience 
teaches  that  such  moral  preachments  seldom  do  any 
good.  On  the  other  hand,  you  will  lose  practice 
this  way.  This  is  especially  true  if  the  patient  is  a 
woman.  Almost  any  woman  who  drinks  alcohol  will 
resent  your  criticism  and  will  manage  to  get  a  phy- 
sician who  will  not  scold  her.  The  only  successful 
way  to  preach  morals  is  to  point  out  the  harm  done 
the  individual  from  a  physical  standpoint,  but  don't 
rail  at  anyone  with  such  statements  as  '*you  dirty 
brute,"  or  ''drunken  sot."  Above  all,  don't  have 
anyone  arrested  because  of  his  or  her  conduct.  Let 
some  one  else  do  those  things.  Don't  try  to  be  the 
arbiter  of  the  morals  of  the  community  wherein  you 
live,  and  try  to  keep  your  wife  from  expressing  her 
opinions  in  such  matters. 


CHAPTER  XXXIX. 

Answebs  to  Patients. 

Have  an  answer  ready  for  every  problem  that 
the  layman  puts  to  you;  don't  hem  and  haw.  Be 
I>ositive  in  all  your  answers.  Anyone  who  fails  to 
study,  and  to  study  hard,  for  the  first  three  years 
of  his  practice  will  be  left  high  and  dry  on  the 
shoals  of  failure.  You  can  all  add  something  to 
the  sum  total  of  knowledge.  The  joy  of  the  dis- 
covery of  a  new  truth,  a  new  means  of  diagnosis 
or  better  method  of  operating,  may  save  hundreds 
of  lives  and  fill  the  soul  with  satisfaction  more 
than  the  plaudits  of  the  multitude. 

As  soon  as  most  patients  place  themselves  in  the 
hands  of  the  physician  they  no  longer  regard  the 
disease,  but  the  physician,  as  responsible  for  their 
suffering.  If  the  patient  continues  to  suffer,  it  is 
because  the  doctor  has  failed  to  relieve  him,  and 
whatever  may  subsequently  happen,  it  is  the  pre- 
scribed medicine  that  is  accountable  for  it.  On  the 
other  hand,  when  owing  to  progress  of  the  disease 
the  sensations  of  the  patient  change,  he  is  tempted 
to  attribute  these  modifications  to  the  measure  of 
treatment.  Don't  ever  give  up  any  case,  with  the 
statement  that  there  is  nothing  more  to  do  for  the 
patient,  or  '*I  can't  do  any  more,"  when  pressed 
by  the  friends.    If  there  is  nothing  else  to  do,  you 

884 


ANSWERS  TO  PATIENTS  286 

can  say  that  at  the  present  moment  there  is  no  other 
remedy,  that  everything  possible  is  being  done,  but 
that  in  a  day  or  two  something  else  will  be  added 
if  a  change  takes  place. 

Don't  complain  of  hard  times,  that  business  is 
very  poor,  etc.  These  statements  are  always  mis- 
construed by  the  layman.  He  will  fear  to  go  to  you, 
thinking  that  you  might  be  tempted  to  make  busi- 
ness. Everyone  wants  a  busy  doctor.  Of  course, 
in  talking  with  doctors,  you  can  be  as  free  as  you 
choose  in  discussing  your  practice. 

If  you  have  time  it  is  much  better  if  all  advice  to 
a  patient  be  written  out  fully  and  not  given  verbally, 
as  it  looks  more  like  an  actual  service  rendered.  It 
will  be  better  remembered  and  more  carefully  fol- 
lowed. This  applies  more  particularly  to  neuras- 
thenics, and  a  letter  to  them,  advising  them  of  the 
safety  of  their  complaint,  which  they  can  carry 
about  and  read  and  reread,  is  often  a  good  thera- 
peutic measure. 

When  you  appoint  an  hour  for  a  return,  call  in 
any  case;  be  prompt,  as  sick  people  are  generally 
watching  the  clock  and  are  easily  disposed  to  be 
querulous  if  disappointed. 

Stoutly  affirm  your  ability  to  do  whatever  you 
undertake;  every  affirmative  strengthens  your  posi- 
tion. The  older  philosophers  have  always  agreed 
that  the  best  strengthener  of  character  and  devel- 
oper of  stamina  is  to  assume  the  part  you  wish  to 
play,  to  stoutly  assert  the  possession  of  whatever 
you  lack.    Be  thoroughly  convinced  that  you  have 


286    BUILDING  A  PROFITABLE  PRACTICE 

such  courage  and  determination  to  win,  and  assert 
them. 

Never  say,  you  think  that  the  disease  is  so  and 
so.  Say  the  patient  is  suffering  from  so  and  so — 
a  definite  disease — that  the  people  can  comprehend. 
Most  people  believe  that  "think"  and  ** guess"  are 
synonymous  terms. 

Develop  a  routine  for  all  sorts  of  emergencies 
that  you  are  apt  to  meet.  When  you  are  suflBciently 
experienced,  you  can  individualize. 

It  is  a  great  misfortune  for  a  young  man  to 
acquire  a  very  extensive  practice  in  the  first  few 
years  of  his  career.  This  may  seem  a  joke,  but  if 
he  does  not  have  the  time  to  read  up  on  all  or  most 
of  his  cases,  he  misses  the  most  valuable  part  of  the 
experience,  i.e.,  a  well-balanced  ground  for  his  fu- 
ture years. 

When  you  are  sent  by  another  doctor  to  go  on  a 
call  for  him,  you  will  often  find  the  people  hostile. 
Be  prepared  for  it,  for  they  will  tell  you  they  don't 
want  any  one  else,  etc.  Go  in  and  sit  down,  osten- 
sibly to  rest  and  chat  a  few  minutes,  expressing 
yourself  entirely  satisfied  and  understanding  their 
feelings,  etc.  You  will  find  that  in  most  cases  be- 
fore you  leave  the  house  they  will  ask  you  to  see 
the  patient.  At  any  rate,  they  will  not  be  ashamed, 
because  of  their  bad  manners,  to  meet  you  at  a  later 
date.  Few  things  will  do  you  more  harm  in  life 
than  to  live  among  people  who  are  ashamed  to  meet 
you. 


ANSWERS  TO  PATIENTS  287 

VACATION,  ETC. 

Don't  think  of  taking  any  vacation  until  you  are 
well  established  in  practice.  If  you  find  yourself 
exhausted  and  in  need  of  a  rest,  after  you  have  been 
in  practice  three  or  more  years,  you  may  safely 
do  so.  Stick  closely  to  business  for  the  first  three 
years;  don't  miss  a  day,  Sunday  included,  unless 
it  be  spent  in  going  to  medical  society  meetings. 
You  will  find  that  this  reputation  of  sticking  to 
business  acquired  during  the  first  three  years,  will 
remain  with  you  the  rest  of  your  life.  Be  at  home 
Sundays  and  holidays,  always  ready  for  calls  when 
other  doctors  are  at  the  seashore  or  picnicking. 

Whenever  you  find  your  interest  in  medicine  de- 
clining, when  you  do  not  get  up  any  enthusiasm 
over  each  strange  case,  then  it  is  time  for  you  to 
take  a  few  weeks  in  some  post-graduate  institution 
or  medical  centre,  where  you  will  get  new  ideas  and 
will  witness  the  enthusiasm  of  others.  You  will  go 
back  resolved  to  do  better  work. 


CHAPTER  XL. 

YouB  Life  Wobk. 

Atteb  the  first  year  in  practice,  pick  out  some 
one  disease,  as  cancer,  diabetes,  etc.,  and  keep  ab- 
stracts of  all  the  articles  that  you  read  on  that  sub- 
ject— not  so  much  with  the  idea  of  becoming  a  spe- 
cialist as  with  the  hope  that  some  time  you  your- 
self may  discover  something  of  importance. 

It  is  my  belief  that  the  progress  of  the  future 
lies,  not  in  surgery,  not  in  obstetrics,  nor  even  in 
the  specialties,  but  rather  in  internal  medicine.  The 
perfection  of  the  technic  of  the  surgical  art  in  all 
its  branches,  of  course,  is  not  by  any  means  com- 
plete yet,  but  it  is  almost  so.  Truly  great  discov- 
eries as  far  as  diseases  affecting  large  numbers  of 
patients  are  concerned  are  necessarily  limited.  The 
common  affections  with  surgical  possibilities  have 
been  so  successfully  handled  that  there  is  little  to 
hope  for;  on  the  other  hand,  the  one  who  discovers 
a  cure  for  cancer,  or  even  a  lead  in  that  direction, 
will  achieve  immortality. 

Li  entering  medicine,  do  so  with  your  whole 
heart  and  soul.  Don't  take  up  any  other  business 
while  you  are  waiting  for  your  practice  to  grow.  No 
one  can  serve  two  masters.  Think  nothing  but  med- 
icine, talk  nothing  but  medicine.  This  is  the  basis 
of  success.    Enthusiasm  in  your  life-work  is  what 

288 


YOUR  LIFE  WORK  289 

will  make  you  a  leader.  There  is  no  profession  in 
which  it  thrives  more  easily  than  in  medicine.  Every 
case  is  different,  every  patient  a  new  disease  in  him- 
self. There  is  no  room  for  ennui.  When  a  botanist 
finds  a  new  specimen,  as  he  rarely  does,  his  enthu- 
siasm and  pleasure  are  unbounded ;  how  much  more 
interesting  should  be  the  finding  of  a  human  speci- 
men differing  from  his  fellow  in  structure  and  dis- 
ease. This  enthusiasm  is  the  best  antidote  to  the 
blues.  This  you  must  cultivate.  You  must  be  en- 
thusiastic and  believe  thoroughly  in  medicine  and 
in  yourself.  Lack  of  enthusiasm  will  fail  to  inspire 
confidence.  It  has  been  said  that  the  human  race  is 
divided  into  two  classes :  those  who  go  ahead  and  do 
something,  and  those  who  sit  still  and  inquire. 
Don't  allow  yourself  to  belong  to  the  second  class. 
After  getting  your  diploma  after  four  years  of  the 
hardest  kind  of  work,  there  should  be  no  such  word 
as  fail. 

Never  forget  that  ours  is  the  most  interesting 
profession  under  the  sun ;  the  greatest  thing  in  life 
must  be  life  itself.  No  profession  or  vocation  offers 
the  same  variety  of  themes.  From  the  spiritual  and 
moral  standpoint,  there  is  no  place  that  you  can  do 
so  much  good;  no  place  where  you  can  so  well  re- 
lieve pain,  both  mental  and  physical.  To  do  this 
effectively  you  must  take  good  care  of  your  own' 
health.  The  laity  believe  that  you  carry  some  charm 
to  ward  off  disease.  The  only  charm  that  you  carry 
is  good  habits  and  hygienic  living.  Most  of  the 
premature  breakdowns  in  the  later  life  of  physi- 

19 


290    BUILDING  A  PROFITABLE  PRACTICE 

cians  are  due  to  neglect  of  these  habits  in  the  first 
few  years  of  practice. 

When  discomfiture  follows  discomfiture;  when 
everything  seems  to  spell  failure,  and  patients  are 
few  and  far  between,  don't  get  disheartened  and 
give  up  as  many  have  done.  About  10  per  cent,  of 
recent  graduates  give  up  the  struggle  just  when 
fortune  is  getting  ready  to  shine  on  them.  To 
everyone  has  come  this  period  of  gloom ;  almost  in- 
variably it  is  the  harbinger  of  sunshine.  Remem- 
ber, that  the  elder  Flint  was  not  a  success  for  many 
years ;  that  Samuel  Gross  was  a  complete  failure  in 
several  places  before  his  genius  was  recognized.  Sir 
Andrew  Clark  divided  the  first  thirty  years  of  prac- 
tice into  three  stages  of  ten  years  each.  The  first 
ten  years  he  called  the  bread  and  water  stage,  the 
second  ten  years  the  bread  and  butter  stage,  and  the 
last  ten  years  the  cake  and  ale  stage. 

Before  you  enter  practice  prepare  yourself  for 
these  days  of  bread  and  water.  Don't  expect  great 
things  for  your  first  year  or  two,  and  by  that  time 
you  will  be  able  to  swim  or  will  be  reconciled  to 
adversity. 


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